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53568 Federal Register / Vol. 82, No.

220 / Thursday, November 16, 2017 / Rules and Regulations

DEPARTMENT OF HEALTH AND ways (please choose only one of the Benjamin Chin, (410) 7860679, for
HUMAN SERVICES ways listed): inquiries related to APMs.
1. Electronically. You may submit SUPPLEMENTARY INFORMATION:
Centers for Medicare & Medicaid electronic comments on this regulation
Services to http://www.regulations.gov. Follow Table of Contents
the Submit a comment instructions. I. Executive Summary and Background
42 CFR Part 414 2. By regular mail. You may mail A. Overview
written comments to the following B. Quality Payment Program Strategic
[CMS5522FC and IFC] address ONLY: Centers for Medicare & Objectives
Medicaid Services, Department of C. One Quality Payment Program
RIN 0938AT13 D. Summary of the Major Provisions
Health and Human Services, Attention:
CMS5522FC or CMS5522IFC (as 1. Quality Payment Program Year 2
Medicare Program; CY 2018 Updates to 2. Small Practices
the Quality Payment Program; and appropriate), P.O. Box 8016, Baltimore,
3. Summary of Major Provisions for
Quality Payment Program: Extreme MD 212448016. Advanced Alternative Payment Models
and Uncontrollable Circumstance Please allow sufficient time for mailed (Advanced APMs)
Policy for the Transition Year comments to be received before the 4. Summary of Major Provisions for the
close of the comment period. Merit-Based Incentive Payment System
AGENCY: Centers for Medicare & 3. By express or overnight mail. You (MIPS)
Medicaid Services (CMS), HHS. may send written comments to the E. Payment Adjustments
ACTION: Final rule with comment period following address ONLY: Centers for F. Benefits and Costs of the Final Rule
and interim final rule with comment Medicare & Medicaid Services, With Comment Period
Department of Health and Human G. Automatic Extreme and Uncontrollable
period. Circumstance Policy Interim Final Rule
Services, Attention: CMS5522FC or
With Comment Period
SUMMARY: The Medicare Access and CMS5522IFC (as appropriate), Mail
H. Stakeholder Input
CHIP Reauthorization Act of 2015 Stop C42605, 7500 Security II. Summary of the Provisions of the
(MACRA) established the Quality Boulevard, Baltimore, MD 212441850. Proposed Regulations, and Analysis of
Payment Program for eligible clinicians. 4. By hand or courier. Alternatively, and Responses to Public Comments
Under the Quality Payment Program, you may deliver (by hand or courier) A. Introduction
eligible clinicians can participate via your written comments ONLY to the B. Definitions
one of two tracks: Advanced Alternative following addresses prior to the close of C. MIPS Program Details
Payment Models (APMs); or the Merit- the comment period: 1. MIPS Eligible Clinicians
based Incentive Payment System a. For delivery in Washington, DC 2. Exclusions
(MIPS). We began implementing the Centers for Medicare & Medicaid 3. Group Reporting
Services, Department of Health and 4. Virtual Groups
Quality Payment Program through 5. MIPS Performance Period
rulemaking for calendar year (CY) 2017. Human Services, Room 445G, Hubert 6. MIPS Category Measures and Activities
This final rule with comment period H. Humphrey Building, 200 7. MIPS Final Score Methodology
provides updates for the second and Independence Avenue SW., 8. MIPS Payment Adjustments
future years of the Quality Payment Washington, DC 20201. 9. Review and Correction of MIPS Final
Program. (Because access to the interior of the Score
In addition, we also are issuing an Hubert H. Humphrey Building is not 10. Third Party Data Submission
interim final rule with comment period readily available to persons without 11. Public Reporting on Physician Compare
(IFC) that addresses extreme and Federal government identification, D. Overview of the APM Incentive
commenters are encouraged to leave 1. Overview
uncontrollable circumstances MIPS 2. Terms and Definitions
eligible clinicians may face as a result their comments in the CMS drop slots
3. Regulation Text Changes
of widespread catastrophic events located in the main lobby of the 4. Advanced APMs
affecting a region or locale in CY 2017, building. A stamp-in clock is available 5. Qualifying APM Participant (QP) and
such as Hurricanes Irma, Harvey and for persons wishing to retain a proof of Partial QP Determinations
Maria. filing by stamping in and retaining an 6. All-Payer Combination Option
extra copy of the comments being filed.) 7. Physician-Focused Payment Models
DATES: b. For delivery in Baltimore, MD (PFPMs)
Effective date: These provisions of Centers for Medicare & Medicaid III. Quality Payment Program: Extreme and
this final rule with comment period and Services, Department of Health and Uncontrollable Circumstances Policy for
interim final rule with comment period Human Services, 7500 Security the Transition Year Interim Final Rule
are effective on January 1, 2018. With Comment Period
Boulevard, Baltimore, MD 212441850.
Comment date: To be assured A. Background
If you intend to deliver your
consideration, comments must be B. Changes to the Extreme and
comments to the Baltimore address, call Uncontrollable Circumstances Policies
received at one of the addresses telephone number (410) 7867195 in for the MIPS Transition Year
provided below, no later than 5 p.m. on advance to schedule your arrival with C. Changes to the Final Score and Policies
January 1, 2018. one of our staff members. Comments for Redistributing the Performance
ADDRESSES: In commenting, please refer erroneously mailed to the addresses Category Weights for the Transition Year
to file code CMS5522FC when indicated as appropriate for hand or D. Changes to the APM Scoring Standard
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commenting on issues in the final rule courier delivery may be delayed and for MIPS Eligible Clinicians in MIPS
with comment period, and CMS5522 received after the comment period. APMs for the Transition Year
IFC when commenting on issues in the For information on viewing public E. Waiver of Proposed Rulemaking for
Provisions Related to Extreme and
interim final rule with comment period. comments, see the beginning of the Uncontrollable Circumstances
Because of staff and resource SUPPLEMENTARY INFORMATION section. IV. Collection of Information Requirements
limitations, we cannot accept comments FOR FURTHER INFORMATION CONTACT: A. Wage Estimates
by facsimile (FAX) transmission. You Molly MacHarris, (410) 7864461, for B. Framework for Understanding the
may submit comments in one of four inquiries related to MIPS. Burden of MIPS Data Submission

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Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations 53569

C. ICR Regarding Burden for Virtual Group CJR Comprehensive Care for Joint I. Executive Summary and Background
Election ( 414.1315) Replacement
D. ICR Regarding Burden for Election of COI Collection of Information A. Overview
Facility-Based Measurement CPR Customary, Prevailing, and Reasonable This final rule with comment period
( 414.1380(e)) CPS Composite Performance Score
E. ICRs Regarding Burden for Third-Party makes payment and policy changes to
CPT Current Procedural Terminology the Quality Payment Program. The
Reporting ( 414.1400) CQM Clinical Quality Measure
F. ICRs Regarding the Quality Performance Medicare Access and CHIP
CY Calendar Year
Category ( 414.1330 and 414.1335) Reauthorization Act of 2015 (MACRA)
eCQM Electronic Clinical Quality Measure
G. ICRs Regarding Burden Estimate for
ED Emergency Department
(Pub. L. 11410, enacted April 16, 2015)
Advancing Care Information Data amended Title XVIII of the Social
( 414.1375) EHR Electronic Health Record
EP Eligible Professional Security Act (the Act) to repeal the
H. ICR Regarding Burden for Improvement Medicare sustainable growth rate (SGR)
Activities Submission ( 414.1355) ESRD End-Stage Renal Disease
I. ICR Regarding Burden for Nomination of FFS Fee-for-Service formula, to reauthorize the Childrens
Improvement Activities ( 414.1360) FR Federal Register Health Insurance Program (CHIP), and
J. ICRs Regarding Burden for Cost FQHC Federally Qualified Health Center to strengthen Medicare access by
( 414.1350) GAO Government Accountability Office improving physician and other clinician
K. ICR Regarding Partial QP Elections HCC Hierarchical Condition Category payments and making other
( 414.1430) HIE Health Information Exchange improvements. The MACRA advances a
L. ICRs Regarding Other Payer Advanced HIPAA Health Insurance Portability and forward-looking, coordinated framework
APM Determinations: Payer-Initiated Accountability Act of 1996 for clinicians to successfully take part in
Process ( 414.1440) and Medicaid HITECH Health Information Technology for
Specific Eligible Clinician Initiated
the Quality Payment Program that
Economic and Clinical Health rewards value and outcomes in one of
Process ( 414.1445) HPSA Health Professional Shortage Area
M. ICRs Regarding Burden for Voluntary two ways:
HHS Department of Health & Human
Participants To Elect Opt Out of Services
Advanced Alternative Payment
Performance Data Display on Physician HRSA Health Resources and Services Models (Advanced APMs).
Compare ( 414.1395)
Administration Merit-based Incentive Payment
N. Summary of Annual Burden Estimates System (MIPS).
IHS Indian Health Service
O. Submission of PRA-Related Comments
IT Information Technology Our goal is to support patients and
P. Collection of Information Requirements
for the Interim Final Rule With Comment LDO Large Dialysis Organization clinicians in making their own
Period: Medicare Program; Quality MACRA Medicare Access and CHIP decisions about health care using data
Payment Program: Extreme and Reauthorization Act of 2015 driven insights, increasingly aligned
Uncontrollable Circumstances Policy for MEI Medicare Economic Index and meaningful quality measures, and
the Transition Year MIPAA Medicare Improvements for innovative technology. To implement
V. Response to Comments Patients and Providers Act of 2008 this vision, the Quality Payment
VI. Regulatory Impact Analysis MIPS Merit-based Incentive Payment Program emphasizes high-value care
A. Statement of Need System
and patient outcomes while minimizing
B. Overall Impact MLR Minimum Loss Rate
MSPB Medicare Spending per Beneficiary
burden on eligible clinicians. The
C. Changes in Medicare Payments
D. Impact on Beneficiaries MSR Minimum Savings Rate Quality Payment Program is also
E. Regulatory Review Costs MUA Medically Underserved Area designed to be flexible, transparent, and
F. Accounting Statement NPI National Provider Identifier structured to improve over time with
G. Regulatory Impact Statement for Interim OCM Oncology Care Model input from clinicians, patients, and
Final Rule With Comment Period: ONC Office of the National Coordinator for other stakeholders.
Medicare Program; Quality Payment Health Information Technology In todays health care system, we
Program: Extreme and Uncontrollable PECOS Medicare Provider Enrollment, often pay doctors and other clinicians
Circumstance Policy for the Transition Chain, and Ownership System based on the number of services they
Year PFPMs Physician-Focused Payment Models perform rather than patient health
Acronyms PFS Physician Fee Schedule outcomes. The good work that clinicians
PHI Protected Health Information
Because of the many terms to which do is not limited to conducting tests or
PHS Public Health Service
we refer by acronym in this rule, we are writing prescriptions, but also taking the
PQRS Physician Quality Reporting System
listing the acronyms used and their PTAC Physician-Focused Payment Model time to have a conversation with a
corresponding meanings in alphabetical Technical Advisory Committee patient about test results, being
order below: QCDR Qualified Clinical Data Registry available to a patient through telehealth
QP Qualifying APM Participant or expanded hours, coordinating
ABCTM Achievable Benchmark of Care medicine and treatments to avoid
QRDA Quality Reporting Document
ACO Accountable Care Organization
Architecture confusion or errors, and developing care
API Application Programming Interface
APM Alternative Payment Model QRUR Quality and Resource Use Reports plans.
APRN Advanced Practice Registered Nurse RBRVS Resource-Based Relative Value The Quality Payment Program takes a
ASC Ambulatory Surgical Center Scale comprehensive approach to payment by
ASPE HHS Office of the Assistant RFI Request for Information basing consideration of quality on a set
Secretary for Planning and Evaluation RHC Rural Health Clinic of evidenced-based measures that were
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BPCI Bundled Payments for Care RIA Regulatory Impact Analysis


primarily developed by clinicians, thus
Improvement RVU Relative Value Unit
SGR Sustainable Growth Rate
encouraging improvement in clinical
CAH Critical Access Hospital practice and supporting by advances in
CAHPS Consumer Assessment of TCPI Transforming Clinical Practice
Healthcare Providers and Systems Initiative technology that allow for the easy
CBSA Core Based Statistical Area TIN Tax Identification Number exchange of information. The Quality
CEHRT Certified EHR Technology VBP Value-Based Purchasing Payment Program also offers special
CFR Code of Federal Regulations VM Value-Based Payment Modifier incentives for those participating in
CHIP Childrens Health Insurance Program VPS Volume Performance Standard certain innovative models of care that

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53570 Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations

provide an alternative to fee-for-service (PQRS), the Physician Value-based customized communication, education,
payment. Payment Modifier (VM), and the outreach and support that meet the
We have sought and will continue to Medicare Electronic Health Record needs of the diversity of physician
seek feedback from the health care (EHR) Incentive Program for Eligible practices and patients, especially the
community through various public Professionals (EPs) and made CY 2017 unique needs of small practices; (5) to
avenues such as rulemaking, listening the transition year for clinicians under improve data and information sharing
sessions and stakeholder engagement. the Quality Payment Program. As on program performance to provide
We understand that technology, prescribed by MACRA, MIPS focuses on accurate, timely, and actionable
infrastructure, physician support the following: (1) Qualityincluding a feedback to clinicians and other
systems, and clinical practices will set of evidence-based, specialty-specific stakeholders; (6) to deliver IT systems
change over the next few years and are standards; (2) cost; (3) practice-based capabilities that meet the needs of users
committed to refine our policies for the improvement activities; and (4) use of for data submission, reporting, and
Quality Payment Program with those certified electronic health record (EHR) improvement and are seamless, efficient
factors in mind. technology (CEHRT) to support and valuable on the front and back-end;
We are aware of the diversity among interoperability and advanced quality and (7) to ensure operation excellence
clinician practices in their experience objectives in a single, cohesive program in program implementation and ongoing
with quality-based payments and expect that avoids redundancies. development; and to design the program
the Quality Payment Program to evolve This CY 2018 final rule with comment in a manner that allows smaller
over multiple years. The groundwork period continues to build and improve independent and rural practices to be
has been laid for expansion toward an upon our transition year policies, as successful. More information on these
innovative, patient-centered, health well as, address elements of MACRA objectives and the Quality Payment
system that is both outcome focused and that were not included in the first year Program can be found at qpp.cms.gov.
resource effective. A system that of the program, including virtual Stakeholder feedback is the hallmark
leverages health information technology groups, beginning with the CY 2019 of the Quality Payment Program. We
to support clinicians and patients and performance period facility-based solicited and reviewed nearly 1,300
builds collaboration across care settings. measurement, and improvement comments and had over 100,000
The Quality Payment Program: (1) scoring. This final rule with comment physicians and other stakeholders
Supports care improvement by focusing period implements policies for Quality attend our outreach sessions to help
on better outcomes for patients, and Payment Program Year 2, some of inform our policies for Quality Payment
preserving the independent clinical which will continue into subsequent Program Year 2. We have set ambitious
practice; (2) promotes the adoption of years of the Quality Payment Program. yet achievable goals for those clinicians
APMs that align incentives for high- We have also included an interim interested in APMs, as they are a vital
quality, low-cost care across healthcare final rule with comment period to part of bending the Medicare cost curve
stakeholders; and (3) advances existing establish an automatic extreme and by encouraging the delivery of high-
delivery system reform efforts, uncontrollable circumstance policy for quality, low-cost care. To allow this
including ensuring a smooth transition the 2017 MIPS performance period that program to work for all stakeholders, we
to a healthcare system that promotes recognizes recent hurricanes (Harvey, further recognize that we must provide
high-value, efficient care through Irma, and Maria) and other natural ongoing education, support, and
unification of CMS legacy programs. disasters can effectively impede a MIPS technical assistance so that clinicians
In the Merit-based Incentive Payment eligible clinicians ability to participate can understand program requirements,
System (MIPS) and Alternative Payment in MIPS. use available tools to enhance their
Model (APM) Incentive under the practices, and improve quality and
Physician Fee Schedule, and Criteria for B. Quality Payment Program Strategic
progress toward participation in APMs
Physician-Focused Payment Models Objectives
if that is the best choice for their
final rule with comment period (81 FR After extensive outreach with practice. Finally, we understand that we
77008, November 4, 2016), referred to as clinicians, patients and other must achieve excellence in program
the CY 2017 Quality Payment Program stakeholders, we created 7 strategic management, focusing on customer
final rule, we established incentives for objectives to drive continued progress needs while also promoting problem-
participation in Advanced APMs, and improvement. These objectives help solving, teamwork, and leadership to
supporting the goals of transitioning guide our final policies and future provide continuous improvements in
from fee-for-service (FFS) payments to rulemaking in order to design, the Quality Payment Program.
payments for quality and value. The CY implement, and advance a Quality
2017 Quality Payment Program final Payment Program that aims to improve C. One Quality Payment Program
rule included definitions and processes health outcomes, promote efficiency, Clinicians have told us that they do
to determine Qualifying APM minimize burden of participation, and not separate their patient care into
Participants (QPs) in Advanced APMs. provide fairness and transparency in domains, and that the Quality Payment
The CY 2017 Quality Payment Program operations. Program needs to reflect typical clinical
final rule also established the criteria for These strategic objectives are as workflows in order to achieve its goal of
use by the Physician-Focused Payment follows: (1) To improve beneficiary better patient care. Advanced APMs, the
Model Technical Advisory Committee outcomes and engage patients through focus of one pathway of the Quality
(PTAC) in making comments and patient-centered Advanced APM and Payment Program, contribute to better
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recommendations to the Secretary on MIPS policies; (2) to enhance clinician care and smarter spending by allowing
proposals for physician-focused experience through flexible and physicians and other clinicians to
payment models (PFPMs). transparent program design and deliver coordinated, customized, high-
The CY 2017 Quality Payment interactions with easy-to-use program value care to their patients in a
Program final rule also established tools; (3) to increase the availability and streamlined and cost-effective manner.
policies to implement MIPS, which adoption of robust Advanced APMs; (4) Within MIPS, the second pathway of the
consolidated certain aspects of the to promote program understanding and Quality Payment Program, we believe
Physician Quality Reporting System maximize participation through that integration into typical clinical

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workflows can best be accomplished by special policies for MIPS Year 2 aimed Payment Program and maximize
making connections across the four at encouraging successful participation participation, and as mandated by the
statutory pillars of the MIPS incentive in the program while reducing burden, statute, during a period of 5 years, $100
structure. Those four pillars are: (1) reducing the number of clinicians million in funding was provided for
Quality; (2) clinical practice required to participate, and preparing technical assistance to be available to
improvement activities (referred to as clinicians for the CY 2019 performance provide guidance and assistance to
improvement activities); (3) period (CY 2021 payment year). Our MIPS eligible clinicians in small
meaningful use of CEHRT (referred to as hope is for the program to evolve to the practices through contracts with
advancing care information); and (4) point where all the clinical activities regional health collaboratives, and
resource use (referred to as cost). captured in MIPS across the four others. Guidance and assistance on the
Although there are two separate performance categories reflect the MIPS performance categories or the
pathways within the Quality Payment single, unified goal of quality transition to APM participation will be
Program, Advanced APMs and MIPS improvement. available to MIPS eligible clinicians in
both contribute toward the goal of practices of 15 or fewer clinicians with
seamless integration of the Quality D. Summary of the Major Provisions
priority given to practices located in
Payment Program into clinical practice 1. Quality Payment Program Year 2 rural areas or medically underserved
workflows. Advanced APMs promote areas (MUAs), and practices with low
this seamless integration by way of We believe the second year of the
Quality Payment Program should build MIPS final scores. More information on
payment methodology and design that the technical assistance support
incentivize care coordination. The MIPS upon the foundation that has been
established which provides a trajectory available to small practices can be found
builds the capacity of eligible clinicians at https://qpp.cms.gov/docs/QPP_
across the four pillars of MIPS to for clinicians to value-based care. A
second year to ramp-up the program Support_for_Small_Practices.pdf.
prepare them for participation in APMs We have also performed an updated
in later years of the Quality Payment will continue to help build upon the
iterative learning and development of regulatory impact analysis, accounting
Program. Indeed, the bedrock of the for flexibilities, many of which are
Quality Payment Program is high-value, year 1 in preparation for a robust
program in year 3. continuing into the Quality Payment
patient-centered care, informed by Program Year 2, that have been created
useful feedback, in a continuous cycle 2. Small Practices to ease the burden for small and solo
of improvement. The principal way that practices.
MIPS measures quality of care is The support of small, independent
through a set of clinical quality practices remains an important thematic 3. Summary of Major Provisions for
measures (CQMs) from which MIPS objective for the implementation of the Advanced Alternative Payment Models
eligible clinicians can select. The CQMs Quality Payment Program and is (Advanced APMs)
are evidence-based, and the vast expected to be carried throughout future
rulemaking. Many small practices did a. Overview
majority are created or supported by
clinicians. Over time, the portfolio of not have to participate in MIPS during APMs represent an important step
quality measures will grow and develop, the transition year due to the low- forward in our efforts to move our
driving towards outcomes that are of the volume threshold, which was set for the healthcare system from volume-based to
greatest importance to patients and CY 2017 performance period at less than value-based care. Our existing APM
clinicians and away from process, or or equal to $30,000 in Medicare Part B policies provide opportunities that
check the box type measures. allowed charges or less than or equal to support state flexibility, local
Through MIPS, we have the 100 Medicare Part B patients. We have leadership, regulatory relief, and
opportunity to measure clinical and heard feedback that many small innovative approaches to improve
patient outcomes, not only through practices still face challenges in their quality, accessibility, and affordability.
evidence-based quality measures, but ability to participate in the program. We APMs that meet the criteria to be
also by accounting for activities that are implementing additional flexibilities Advanced APMs provide the pathway
clinicians and patients themselves for Year 2 including: Implementing the through which eligible clinicians, many
identify: Namely, practice-driven virtual groups provisions; increasing the of whom who would otherwise fall
quality improvement. MIPS also low-volume threshold to less than or under the MIPS, can become Qualifying
requires us to assess whether CEHRT is equal to $90,000 in Medicare Part B APM Participants (QPs), thereby earning
used in a meaningful way and based on allowed charges or less than or equal to incentives for their Advanced APM
significant feedback, this area was 200 Medicare Part B patients; adding a participation. In the CY 2017 Quality
simplified to support the exchange of significant hardship exception from the Payment Program final rule, we
patient information, engagement of advancing care information performance estimated that 70,000 to 120,000 eligible
patients in their own care through category for MIPS eligible clinicians in clinicians would be QPs for payment
technology, and the way technology small practices; providing 3 points even year 2019 based on Advanced APM
specifically supports the quality goals if small practices submit quality participation in performance year 2017
selected by the practice. And lastly, measures below data completeness (81 FR 77516). With new Advanced
MIPS requires us to measure the cost of standards; and providing bonus points APMs expected to be available for
services provided through the cost that are added to the final scores of participation in 2018, including the
performance category, which will MIPS eligible clinicians who are in Medicare ACO Track 1 Plus (1+) Model,
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contribute to a MIPS eligible clinicians small practices. We believe that these and the addition of new participants for
final score beginning in the second year additional flexibilities and reduction in some current Advanced APMs, such as
of the MIPS. barriers will further enhance the ability the Next Generation ACO Model and
We realize the Quality Payment of small practices to participate Comprehensive Primary Care Plus
Program is a big change. In this final successfully in the Quality Payment (CPC+) Model, we anticipate higher
rule with comment period, we continue Program. numbers of QPs in subsequent years of
the slow ramp-up of the Quality In keeping with the objectives to the program. We currently estimate that
Payment Program by establishing provide education about the Quality approximately 185,000 to 250,000

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eligible clinicians may become QPs for Eligible clinicians who participate in 8 percent of the total combined
payment year 2020 based on Advanced Advanced APMs but do not meet the QP revenues from the payer of providers
APM participation in performance year or Partial QP thresholds are subject to and suppliers in participating APM
2018. MIPS reporting requirements and Entities only for arrangements that are
payment adjustments unless they are expressly defined in terms of revenue.
b. Advanced APMs otherwise excluded from MIPS. We are also finalizing a more gradual
In the CY 2017 Quality Payment ramp-up in percentages of revenue for
d. All-Payer Combination Option
Program final rule, to be considered an the Medicaid Medical Home Model
Advanced APM, we finalized that an The All-Payer Combination Option, nominal amount standard over the next
APM must meet all three of the which uses a calculation based on an several years.
following criteria, as required under eligible clinicians participation in both We are finalizing the Payer Initiated
section 1833(z)(3)(D) of the Act: (1) The Advanced APMs and Other Payer and Eligible Clinician Other Payer
APM must require participants to use Advanced APMs to make QP Advanced APM determination
CEHRT; (2) The APM must provide for determinations, is applicable beginning processes to allow payers, APM Entities,
payment for covered professional in performance year 2019. To become a or eligible clinicians to request that we
services based on quality measures QP through the All-Payer Combination determine whether other payer
comparable to those in the quality Option, an eligible clinician must arrangements meet the Other Payer
performance category under MIPS; and participate in an Advanced APM with Advanced APM criteria. We have also
(3) The APM must either require that CMS as well as an Other Payer finalized requirements pertaining to the
participating APM Entities bear risk for Advanced APM. We determine whether submission of information.
monetary losses of a more than nominal other payer arrangements are Other We are finalizing certain
amount under the APM, or be a Medical Payer Advanced APMs based on modifications to how we calculate
Home Model expanded under section information submitted to us by eligible Threshold Scores and make QP
1115A(c) of the Act (81 FR 77408). clinicians, APM Entities, and in some determinations under the All-Payer
cases by payers, including states and Combination Option. We are retaining
We are maintaining the generally
Medicare Advantage Organizations. In the QP Performance Period for the All-
applicable revenue-based nominal
addition, the eligible clinician or the Payer Combination Option from January
amount standard at 8 percent for QP
APM Entity must submit information to 1 through August 31 of each year as
Performance Periods 2019 and 2020. We CMS so that we can determine whether finalized in the CY 2017 Quality
are exempting participants in Round 1 the eligible clinician meets the requisite Payment Program final rule.
of the CPC+ Model as of January 1, 2017 QP threshold of participation.
from the 50 eligible clinician limit as To be an Other Payer Advanced APM, e. Physician-Focused Payment Models
proposed. We are also finalizing a more as set forth in section 1833(z)(2)(B)(ii) (PFPMs)
gradual ramp-up in percentages of and (C)(ii) of the Act and implemented The PTAC is an 11-member federal
revenue for the Medical Home Model in the CY 2017 Quality Payment advisory committee that is an important
nominal amount standard over the next Program final rule, a payment avenue for the creation of innovative
several years. arrangement with a payer (for example, payment models. The PTAC is charged
c. Qualifying APM Participant (QP) and payment arrangements authorized under with reviewing stakeholders proposed
Partial QP Determinations Title XIX, Medicare Health Plan PFPMs, and making comments and
payment arrangements, and payment recommendations to the Secretary
QPs are eligible clinicians in an arrangements in CMS Multi-Payer regarding whether they meet the PFPM
Advanced APM who have met a Models) must meet all three of the criteria established by the Secretary
threshold percentage of their patients or following criteria: (1) CEHRT is used; (2) through rulemaking in the CY 2017
payments through an Advanced APM the payment arrangement must require Quality Payment Program final rule. The
or, beginning in performance year 2019, the use of quality measures comparable Secretary is required to review the
attain QP status through the All-Payer to those in the quality performance comments and recommendations
Combination Option. Eligible clinicians category under MIPS; and (3) the submitted by the PTAC and post a
who are QPs for a year are excluded payment arrangement must either detailed response to these
from the MIPS reporting requirements require the APM Entities to bear more recommendations on the CMS Web site.
and payment adjustment for the year, than nominal financial risk if actual We sought comments on broadening
and receive a 5 percent APM Incentive aggregate expenditures exceed expected the definition of PFPM to include
Payment for the year in years from 2019 aggregate expenditures, or be a payment arrangements that involve
through 2024. The statute sets Medicaid Medical Home Model that Medicaid or the Childrens Health
thresholds for the level of participation meets criteria comparable to Medical Insurance Program (CHIP) as a payer
in Advanced APMs required for an Home Models expanded under section even if Medicare is not included as a
eligible clinician to become a QP for a 1115A(c) of the Act. payer. We are maintaining the current
year. In this final rule with comment definition of a PFPM to include only
We are finalizing that for Advanced period, we are finalizing policies that payment arrangements with Medicare as
APMs that start or end during the QP provide more detail about how the All- a payer. We believe this definition
Performance Period and operate Payer Combination Option will operate. retains focus on APMs and Advanced
continuously for a minimum of 60 days We are finalizing that an other payer APMs, which would be proposals that
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during the QP Performance Period for arrangement would meet the generally the Secretary has more direct authority
the year, we are making QP applicable revenue-based nominal to implement, while maintaining
determinations using payment or amount standard we proposed if, under consistency for PTACs review while
patient data only for the dates that APM the terms of the other payer they are still refining their processes. In
Entities were able to participate in the arrangement, the total amount that an addition, we sought comment on the
Advanced APM per the terms of the APM Entity potentially owes the payer Secretarys criteria and stakeholders
Advanced APM, not for the full QP or foregoes is equal to at least: For the needs in developing PFPM proposals
Performance Period. 2019 and 2020 QP Performance Periods, aimed at meeting the criteria.

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4. Summary of Major Provisions for the Medicare Part B claims. While we Improvement Activities Inventory.
Merit-Based Incentive Payment System proposed to maintain a 50 percent data Specifically, as discussed in the
(MIPS) completeness threshold for the 2018 appendices (Tables F and G) of this final
For Quality Payment Program Year 2, MIPS performance period, we are not rule with comment period, we are
which is the second year of the MIPS finalizing this proposal and will be finalizing 21 new improvement
and includes the 2018 performance keeping our previously finalized data activities (some with modification) and
period and the 2020 MIPS payment completeness threshold of 60 percent changes to 27 previously adopted
year, as well as the following: for data submitted on quality measures improvement activities (some with
using QCDRs, qualified registries, EHR, modification and including 1 removal)
a. Quality or Medicare Part B claims for the 2018 for the Quality Payment Program Year 2
We previously finalized that the MIPS performance period. We also and future years (2018 MIPS
quality performance category would proposed to have the data completeness performance period and future years)
comprise 60 percent of the final score threshold for the 2021 MIPS payment Improvement Activities Inventory.
for the transition year and 50 percent of year (2019 performance period) to 60 These activities were recommended by
the final score for the 2020 MIPS percent for data submitted on quality clinicians, patients and other
payment year (81 FR 77100). While we measures using QCDRs, qualified stakeholders interested in advancing
proposed to maintain a 60 percent registries, EHR, or Medicare Part B quality improvement and innovations in
weight for the quality performance claims. We are also finalizing this healthcare. We will continue to seek
category for the 2020 MIPS payment proposal. We anticipate that as MIPS new improvement activities as the
year, we are not finalizing this proposal eligible clinicians gain experience with program evolves. Additionally, we are
and will be keeping our previously the MIPS we will propose to further finalizing several policies related to
increase these thresholds over time. submission of improvement activities.
finalized policy to weight the quality
In particular, we are formalizing the
performance category at 50 percent for b. Improvement Activities
annual call for activities process for
the 2020 MIPS payment year. We are Improvement activities are those that Quality Payment Program Year 3 and
also finalizing that for purposes of the improve clinical practice or care future years. We are finalizing with
2021 MIPS payment year, the delivery and that, when effectively modification, for the Quality Payment
performance period for the quality and executed, are likely to result in Program Year 3 and future years, that
cost performance categories is CY 2019 improved outcomes. We believe stakeholders should apply one or more
(January 1, 2019 through December 31, improvement activities support broad of the criteria when submitting
2019). We note that we had previously aims within healthcare delivery, improvement activities in response to
finalized that for the purposes of the including care coordination, beneficiary the Annual Call for Activities. In
2020 MIPS payment year the engagement, population management, addition to the criteria listed in the
performance period for the quality and and health equity. For the 2020 MIPS proposed rule for nominating new
cost performance categories is CY 2018 payment year, we previously finalized improvement activities for the Annual
(January 1, 2018 through December 31, that the improvement activities Call for Activities policy, we are
2018). We did not make proposals to performance category would comprise modifying and expanding the proposed
modify this time frame in the CY 2018 15 percent of the final score (81 FR criteria list to also include: (1)
Quality Payment Program proposed rule 77179). There are no changes in Improvement activities that focus on
and are therefore unable to modify this improvement activities scoring for meaningful actions from the person and
performance period. Quality Payment Program Year 2 (2018 familys point of view, and (2)
Quality measures are selected MIPS performance period) as discussed improvement activities that support the
annually through a call for quality in section II.C.7.a.(5) of this final rule patients family or personal caregiver. In
measures under consideration, with a with comment period. However, in this addition, we are finalizing to: (1) Accept
final list of quality measures being final rule, we are finalizing our proposal submissions for prospective
published in the Federal Register by to no longer require self-identifications improvement activities at any time
November 1 of each year. We are for non-patient facing MIPS eligible during the performance period for the
finalizing for the CAHPS for MIPS clinicians, small practices, practices Annual Call for Activities and create an
survey for the Quality Payment Program located in rural areas or geographic Improvement Activities Under Review
Year 2 and future years that the survey HPSAs, or any combination thereof, (IAUR) list; (2) only consider
administration period will, at a beginning with the 2018 MIPS prospective activities submitted by
minimum, span over 8 weeks and, at a performance period and for future years. March 1 for inclusion in the
maximum, 17 weeks and will end no We are finalizing that for Quality Improvement Activities Inventory for
later than February 28th following the Payment Program Year 2 and future the performance periods occurring in
applicable performance period. In years (2018 MIPS performance period the following calendar year; and (3) add
addition, we are finalizing for the and future years), MIPS eligible new improvement activities and
Quality Payment Program Year 2 and clinicians or groups must submit data subcategories through notice-and-
future years to remove two Summary on improvement activities in one of the comment rulemaking in future years of
Survey Modules (SSMs), specifically, following manners: Via qualified the Quality Payment Program.
Helping You to Take Medication as registries, EHR submission mechanisms, Additionally, we are finalizing that
Directed and Between Visit QCDR, CMS Web Interface, or for purposes of the 2021 MIPS payment
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Communication from the CAHPS for attestation; and that for activities that year, the performance period for the
MIPS survey. are performed for at least a continuous improvement activities performance
For the 2018 MIPS performance 90 days during the performance period, category is a minimum of a continuous
period, we previously finalized that the MIPS eligible clinicians must submit a 90-day period within CY 2019, up to
data completeness threshold would yes response for activities within the and including the full CY 2019 (January
increase to 60 percent for data Improvement Activities Inventory. 1, 2019 through December 31, 2019).
submitted on quality measures using In this final rule with comment In this final rule with comment
QCDRs, qualified registries, via EHR, or period, we are finalizing updates to the period, we are also expanding our

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definition of how we will recognize an category focus on the secure exchange of decertified EHR technology, and
individual MIPS eligible clinician or health information and the use of significant hardship exceptions under
group as being a certified patient- CEHRT to support patient engagement the MIPS. We are also finalizing a
centered medical home or comparable and improved healthcare quality. While significant hardship exception for MIPS
specialty practice. We are finalizing our we continue to recommend that eligible clinicians in small practices. For
proposal, with clarification, that at least physicians and clinicians migrate to the clinicians requesting a reweighting of
50 percent of the practice sites within implementation and use of EHR the advancing care information
the TIN must be recognized as a patient- technology certified to the 2015 Edition performance category, we are changing
centered medical home or comparable so they may take advantage of improved the deadline for submission of this
specialty practice to receive full credit functionalities, including care application to December 31 of the
as a certified or recognized patient- coordination and technical performance period. Lastly, we are
centered medical home or comparable advancements such as application
finalizing additional improvement
specialty practice for the 2020 MIPS programming interfaces, or APIs, we
activities that are eligible for a 10
payment year and future years. We are recognize that some practices may have
clarifying that a practice site as is the challenges in adopting new certified percent bonus under the advancing care
physical location where services are health IT. Therefore, we are finalizing information performance category if
delivered. We proposed in section that MIPS eligible clinicians may they are completed using CEHRT.
II.C.6.e.(3)(b) of the proposed rule (82 continue to use EHR technology d. Cost
FR 30054) that eligible clinicians in certified to the 2014 Edition for the
practices that have been randomized to performance period in CY 2018. We previously finalized that the cost
the control group in the CPC+ model Clinicians may also choose to use the performance category would comprise
would also receive full credit as a 2015 Edition CEHRT or a combination zero percent of the final score for the
Medical Home Model. We are not of the two. Clinicians will earn a bonus transition year and 10 percent of the
finalizing this proposal, however, for using only 2015 CEHRT in 2018. final score for the 2020 MIPS payment
because CMMI has not randomized any For the 2018 performance period, year (81 FR 77165). For the 2020 MIPS
practices into a control group in CPC+ MIPS eligible clinicians will have the payment year, we proposed to change
Round 2. option to report the Advancing Care the weight of the cost performance
We are also finalizing changes to the Information Transition Objectives and category from 10 percent to zero percent
study, including modifying the name to Measures using 2014 Edition CEHRT, (82 FR 30047). For the 2020 MIPS
the CMS Study on Burdens Associated 2015 Edition CEHRT, or a combination payment year, we are finalizing a 10
with Reporting Quality Measures, of 2014 and 2015 Edition CEHRT, as
percent weight for the cost performance
increasing the sample size for 2018, and long as the EHR technology they possess
category in the final score in order to
updating requirements. can support the objectives and measures
Furthermore, in recognition of to which they plan to attest. Similarly, ease the transition to a 30 percent
improvement activities as supporting MIPS eligible clinicians will have the weight for the cost performance category
the central mission of a unified Quality option to attest to the Advancing Care in the 2021 MIPS payment year. For the
Payment Program, we are finalizing in Information Objectives and Measures 2018 MIPS performance period, we are
section II.C.6.e.(3)(a) of this final rule using 2015 Edition CEHRT or a adopting the total per capita costs for all
with comment period to continue to combination of 2014 and 2015 Edition attributed beneficiaries measure and the
designate activities in the Improvement CEHRT, as long as their EHR technology Medicare Spending per Beneficiary
Activities Inventory that will also can support the objectives and measures (MSPB) measure that were adopted for
qualify for the advancing care to which they plan to attest. the 2017 MIPS performance period, and
information bonus score. This is We are finalizing exclusions for the e- we will not use the 10 episode-based
consistent with our desire to recognize Prescribing and Health Information measures that were adopted for the 2017
that CEHRT is often deployed to Exchange Objectives beginning with the MIPS performance period. Although
improve care in ways that our programs 2017 performance period. We are also data on the episode-based measures has
should recognize. finalizing that eligible clinicians can been made available to clinicians in the
earn 10 percentage points in their past, we are in the process of developing
c. Advancing Care Information performance score for reporting to any new episode-based measures with
For the Quality Payment Program single public health agency or clinical significant clinician input and believe it
Year 2, the advancing care information data registry to meet any of the would be more prudent to introduce
performance category is 25 percent of measures associated with the Public these new measures over time. We will
the final score. However, if a MIPS Health and Clinical Data Registry continue to offer performance feedback
eligible clinician is participating in a Reporting objective (or any of the on episode-based measures prior to
MIPS APM the advancing care measures associated with the Public
potential inclusion of these measures in
information performance category may Health Reporting Objective of the 2018
MIPS to increase clinician familiarity
be 30 percent or 75 percent of the final Advancing Care Information Transition
score depending on the availability of Objectives and Measures, for clinicians with the concept as well as specific
APM quality data for reporting. We are who choose to report on those episode-based measures. Specifically,
finalizing that for purposes of the 2021 measures) and, and will award an we are providing feedback on these new
MIPS payment year, the performance additional 5 percentage point bonus for episode-based cost measures for
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period for advancing care information reporting to more than one. We are informational purposes only. We intend
performance category is a minimum of implementing several provisions of the to provide performance feedback on the
a continuous 90-day period within CY 21st Century Cures Act (Pub. L. 114 MSPB and total per capita cost measures
2019, up to and including the full CY 255, enacted on December 13, 2016) by July 1, 2018, consistent with section
2019 (January 1, 2019 through December pertaining to hospital-based MIPS 1848(q)(12) of the Act. In addition, we
31, 2019). eligible clinicians, ambulatory surgical intend to offer feedback on newly
Objectives and measures in the center-based MIPS eligible clinicians, developed episode-based cost measures
advancing care information performance MIPS eligible clinicians using in 2018 as well.

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e. Submission Mechanisms practitioners or one or more groups g. MIPS APMs


We are finalizing additional flexibility consisting of 10 or fewer eligible
clinicians that elect to form a virtual MIPS eligible clinicians who
for submitting data through multiple participate in MIPS APMs are scored
submission mechanisms. Due to group for a performance period for a
year. In order for solo practitioners or using the APM scoring standard instead
operational reasons and to allow of the generally applicable MIPS scoring
additional time to communicate how such groups to be eligible to join a
virtual group, the solo practitioners and standard. For the 2018 performance
this policy intersects with our measure period, we are finalizing modifications
applicability policies, this policy will the groups would need to exceed the
low-volume threshold. A solo to the quality performance category
not be implemented for the 2018 reporting requirements and scoring for
performance period but will be practitioner or a group that does not
MIPS eligible clinicians in MIPS APMs,
implemented instead for the 2019 exceed the low-volume threshold could
and other modifications to the APM
performance period of the Quality not participate in a virtual group, and it
scoring standard. For purposes of the
Payment Program. Individual MIPS is not permissible under the statute to
APM scoring standard, we are adding a
eligible clinicians or groups will be able apply the low-volume threshold at the
fourth snapshot date that would be used
to submit measures and activities, as virtual group level. Also, we are
only to identify eligible clinicians in
available and applicable, via as many finalizing our virtual group policies to
APM Entity groups participating in
mechanisms as necessary to meet the clearly delineate those group-related
those MIPS APMs that require full TIN
requirements of the quality, policies that apply to virtual groups
participation. This snapshot date will
improvement activities, or advancing versus policies that only apply to virtual
not be used to make QP determinations.
care information performance categories groups.
Along with the other APM Entity
for the 2019 performance period. This Virtual groups are required to make groups, these APM Entity groups would
option will provide clinicians the ability an election to participate in MIPS as a be used for the purposes of reporting
to select the measures most meaningful virtual group prior to the start of an and scoring under the APM scoring
to them, regardless of the submission applicable performance period. We are standard described in the CY 2017
mechanism. also finalizing a two-stage virtual group Quality Payment Program final rule (81
Also, given stakeholder concerns election process for the applicable 2018 FR 77246).
regarding CMS multiple submissions and 2019 performance periods. The first
mechanism policy, we want to clarify stage is the optional eligibility stage, but h. Facility-Based Measurement
that under the validation process for for practices that do not choose to We solicited comments on
Year 3, MIPS eligible clinicians who participate in stage 1 of the election implementing facility-based
submit via claims or registry submission process, we will make an eligibility measurement for the 2018 MIPS
only or a combination of claims and determination during stage 2 of the performance period and future
registry submissions would not be election process. The second stage is the performance periods to add more
required to submit measures through virtual group formation stage. We are flexibility for clinicians to be assessed
other mechanisms to meet the quality also finalizing that virtual groups must in the context of the facilities at which
performance category criteria; rather, it have a formal written agreement among they work. We described facility-based
is an option available to MIPS eligible each party of a virtual group. The measures policies related to applicable
clinicians which may increase their election deadline will be December 31. measures, applicability to facility-based
quality performance category score. We measurement, group participation, and
To provide support and reduce
expect that MIPS eligible clinicians facility attribution. For clinicians whose
burden, we intend to make technical
would choose the submission primary professional responsibilities are
assistance (TA) available, to the extent
mechanism that would give them 6 in a healthcare facility we presented a
feasible and appropriate, to support
measures to report. Our intention is to method to assess performance in the
clinicians who choose to come together
offer multiple submission mechanisms quality and cost performance categories
as a virtual group for the first 2 years of
to increase flexibility for MIPS of MIPS based on the performance of
virtual group implementation applicable
individual clinicians and groups. We that facility in another value-based
to the 2018 and 2019 performance years.
are not requiring that MIPS individual purchasing program.
Clinicians already receiving technical
clinicians and groups submit via
assistance may continue to do so for After much consideration, we are
additional submission mechanisms;
virtual groups support; otherwise, the finalizing our proposal to allow
however, through this policy the option
Quality Payment Service Center is clinicians to use facility-based
would be available for those that have
available to assist and connect virtual measurement in year 3 (2019) of the
applicable measures and/or activities
groups with a technical assistance Quality Payment Program. We will use
available to them.
representative. For year 2, we believe the 2018 year to ensure that clinicians
f. Virtual Groups that we have created an election process better understand the opportunity and
Virtual groups are a new way to that is simple and straightforward. For ensure operational readiness to offer
participate in MIPS starting with the Quality Payment Program Year 3, we facility-based measurement.
2018 MIPS performance period. For the intend to provide an electronic election
process, if technically feasible. i. Scoring
2018 performance period, clinicians can
participate in MIPS as an individual, as Virtual groups are required to meet In the transition year of the Quality
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a group, as an APM Entity in a MIPS the requirements for each performance Payment Program, we finalized a
APM, or as a virtual group. category and responsible for aggregating unified scoring system to determine a
For the implementation of virtual data for their measures and activities final score across the 4 performance
groups as a participation option under across the virtual group, for example, categories (81 FR 77273 through 77276).
MIPS, we are establishing the following across their TINs. In future years, we For the 2018 MIPS performance period,
policies. We are defining a virtual group intend to examine how we define we will build on the scoring
as a combination of two or more TINs group under MIPS with respect to methodology we finalized for the
assigned to one or more solo flexibility in composition and reporting. transition year, focusing on encouraging

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MIPS eligible clinicians to meet data score, or be reweighted if a performance are finalizing the use of a simplified
completeness requirements. category score is not available. self-nomination process for previously
For quality performance category We are also finalizing small practice approved QCDRs and qualified
scoring, we are finalizing to extend and complex patient bonuses only for registries in good standing.
some of the transition year policies to the 2020 MIPS payment year. The small In addition, regarding information a
the 2018 MIPS performance period and practice bonus of 5 points will be QCDR specifically must provide to us at
also finalizing several modifications to applied to the final score for MIPS the time of self-nomination, we are
existing policy. Quality measures that eligible clinicians in groups, virtual making a number of clarifications,
can be scored against a benchmark that groups, or APM Entities that have 15 or finalized that the term QCDR
meet data completeness standards, and fewer clinicians and that submit data on measures will replace the existing term
meet the minimum case size at least one performance category in the of non-MIPS measures, and sought
requirements will continue to receive 2018 performance period. We will also public input on requiring full
between 3 and 10 points as measure apply a complex patient bonus capped development and testing of QCDR
achievement points. Measures that do at 5 points using the dual eligibility measures by submission. We have also
not have a benchmark or meet the case ratio and average HCC risk score. We made a few clarifications to existing
minimum requirement will continue to increased the complex patients bonus criteria as they pertain to qualified
receive 3 points. from 3 points as proposed in part to registries.
For quality data submitted via EHR, align with the small practice bonus. The We are not making any changes to the
QCDR, or qualified registry, we are final score will be compared against the health IT vendors that obtain data from
lowering the number of points available MIPS performance threshold of 15 CEHRT requirements. Regarding CMS-
for measures that do not meet the data points for the 2020 MIPS payment year, approved survey vendors, we are
completeness criteria to 1 point, except a modest increase from 3 points in the finalizing that for the Quality Payment
for a measure submitted by a small transition year. A 15-point final score Program year 2 and for future years, that
practice, which we will continue to equal to the performance threshold can the vendor application deadline be
assign 3 points. be achieved via multiple pathways and January 31st of the applicable
We are finalizing a timeline to continues the gradual transition into performance year or a later date
identify and propose to remove topped MIPS. The additional performance specified by CMS. Lastly, based on
out quality measures through future threshold for exceptional performance comments we received on the 10-year
rulemaking. We are evaluating will remain at 70 points, the same as for record retention period and our interest
additional considerations needed to the transition year. in reducing financial and time burdens
maintain measures for important aspects We are finalizing a policy of applying
under this program and having
of care, such as patient safety and high the MIPS payment adjustment to the
consistent policies across this program,
reliability, and will address this in Medicare paid amount.
we are aligning our record retention
future rulemaking. We are finalizing a j. Performance Feedback period across the program by modifying
policy of applying a scoring cap to We proposed and are finalizing the our proposal for third parties from 10
identified topped out measures with policy to provide Quality Payment years to finalize a 6-year retention
measure benchmarks that have been Program performance feedback to period. Therefore, we are finalizing that
topped out for at least 2 consecutive eligible clinicians and groups. Initially, entities must retain all data submitted to
years; however, based on feedback, we we will provide performance feedback us for purposes of MIPS for a 6 years
will award up to 7 points for topped out on an annual basis. In future years, we from the end of the MIPS performance
measures rather than the 6 points aim to provide performance feedback on period.
originally proposed. We are finalizing a more frequent basis, which is in line
the special scoring policy for the 6 l. Public Reporting
with clinician requests for timely,
measures identified for the 2018 actionable feedback that they can use to As discussed in section II.C.11. of this
performance period with a 7-point improve care. final rule with comment period, we
scoring cap. proposed and are finalizing public
We are also excluding CMS Web k. Third Party Intermediaries reporting of certain eligible clinician
Interface measures from topped out In the CY 2017 Quality Payment and group Quality Payment Program
scoring, but we will continue to monitor Program final rule (81 FR 77362), we information, including MIPS and APM
differences between CMS Web Interface finalized that qualified registries, data in an easily understandable format
and other submission options. We QCDRs, health IT vendors, and CMS- as required under the MACRA.
intend to address CAHPS through future approved survey vendors will have the m. Eligibility and Exclusion Provisions
rulemaking. ability to act as intermediaries on behalf of the MIPS Program
Beginning with the 2018 MIPS of individual MIPS eligible clinicians
performance period, we are finalizing and groups for submission of data to We are modifying the definition of a
measuring improvement scoring at the CMS across the quality, improvement non-patient facing MIPS eligible
performance category level for the activities, and advancing care clinician to apply to virtual groups. In
quality performance category, but we information performance categories. addition, we are finalizing our proposal
will monitor this approach and revisit Regarding QCDRs and qualified to specify that groups considered to be
as needed through future rule making. registries, we are finalizing our proposal non-patient facing (more than 75
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We are finalizing measuring to eliminate the self-nomination percent of the NPIs billing under the
improvement scoring at the measure submission method of email and require groups TIN meet the definition of a
level for the cost performance category. that QCDRs and qualified registries non-patient facing individual MIPS
For the 2018 MIPS performance submit their self-nomination eligible clinician) during the non-
period, the quality, improvement applications via a web-based tool for patient facing determination period
activities, cost and advancing care future program years beginning with the would automatically have their
information performance category 2018 performance period. Beginning advancing care information performance
scores will be given weight in the final with the 2019 performance period, we category reweighted to zero.

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Additionally, we are finalizing our on specified measures and activities expenditures include approximately
proposal to increase the low-volume within four integrated performance $675$900 million in APM incentive
threshold to less than or equal to categories. payments to QPs.
$90,000 in Medicare Part B allowed Assuming that 90 percent of MIPS
eligible clinicians of all practice sizes G. Automatic Extreme and
charges or 200 or fewer Part-B enrolled
participate in MIPS, we estimate that Uncontrollable Circumstance Policy
Medicare beneficiaries to further
MIPS payment adjustments will be Interim Final Rule With Comment
decrease burden on MIPS eligible
approximately equally distributed Period
clinicians that practice in rural areas or
are part of a small practice or are solo between negative MIPS payment In order to account for Hurricanes
practitioners. We are not finalizing our adjustments of $118 million and Harvey, Irma, and Maria and other
proposal to provide clinicians the positive MIPS payment adjustments of disasters that have occurred or might
ability to opt-in to MIPS if they meet or $118 million to MIPS eligible clinicians, occur during the 2017 MIPS
exceed one, but not all, of the low- as required by the statute to ensure performance period, we are establishing
volume threshold determinations, budget neutrality. Positive MIPS in an interim final rule with comment
including as defined by dollar amount, payment adjustments will also include period an automatic extreme and
beneficiary count or, if established, up to an additional $500 million for uncontrollable circumstance policy for
items and services. We intend to revisit exceptional performance to MIPS the quality, improvement activities, and
this policy in future rulemaking and are eligible clinicians whose final score advancing care information performance
seeking comment on methods to meets or exceeds the additional categories for the 2017 MIPS
implement this policy in a low burden performance threshold of 70 points. performance period. We believe the
manner. These MIPS payment adjustments are automatic extreme and uncontrollable
expected to drive quality improvement circumstance policy will reduce
E. Payment Adjustments in the provision of MIPS eligible clinician burden during a catastrophic
For the 2020 payment year based on clinicians care to Medicare time and will also align with Medicare
Advanced APM participation in 2018 beneficiaries and to all patients in the policies in other programs such as the
performance period, we estimated that health care system. However, the Hospital IQR Program. Under this
approximately 185,000 to 250,000 distribution will change based on the policy, we will apply the extreme and
clinicians will become QPs, and final population of MIPS eligible uncontrollable circumstance policies for
therefore, be excluded from the MIPS clinicians for CY 2020 and the the MIPS performance categories to
reporting requirements and payment distribution of scores under the individual MIPS eligible clinicians for
adjustment, and qualify for a lump sum program. We believe that starting with the 2017 MIPS performance period
APM incentive payment equal to 5 these modest initial MIPS payment without requiring a MIPS eligible
percent of their estimated aggregate adjustments is in the long-term best clinician to submit an application when
payment amounts for covered interest of maximizing participation and we determine a triggering event, such as
professional services in the preceding starting the Quality Payment Program a hurricane, has occurred and the
year. We estimate that the total lump off on the right foot, even if it limits the clinician is in an affected area. We will
sum APM incentive payments will be magnitude of MIPS positive adjustments automatically weight the quality,
between approximately $675 million during the 2018 MIPS performance improvement activities, and advancing
and $900 million for the 2020 Quality period. The increased availability of care information performance categories
Payment Program payment year. This Advanced APM opportunities, at zero percent of the final score,
expected growth in QPs between the including through Medical Home resulting in a final score equal to the
first and second year of the program is models, also provides earlier avenues to performance threshold, unless the MIPS
due in part to reopening of CPC+ and earn APM incentive payments for those eligible clinician submits MIPS data
Next Generation ACO for 2018, and the eligible clinicians who choose to which we would then score on a
Medicare ACO Track 1+ Model which is participate. performance-category-by-performance-
projected to have a large number of category-basis, like all other MIPS
participants, with a large majority F. Benefits and Costs of the Final Rule eligible clinicians. We are not making
reaching QP status. With Comment Period any changes to the APM scoring
Under the policies in this final rule We quantify several costs associated standard policies that apply in 2017 for
with comment period, and for purposes with this rule. We estimate that this participants in MIPS APMs. We are
of the Regulatory Impact Analysis, we final rule with comment period will waiving notice and comment and
estimate that approximately 622,000 result in approximately $694 million in adopting this policy on an interim final
eligible clinicians will be subject to collection of information-related basis due to the urgency of providing
MIPS reporting requirements and burden. We estimate that the relief for MIPS eligible clinicians
payment adjustments in the 2018 MIPS incremental collection of information- impacted by recent natural disasters
performance period. However, this related burden associated with this final during the 2017 MIPS performance
number may vary depending on the rule with comment period is a reduction period.
number of eligible clinicians excluded of approximately $13.9 million relative
from MIPS based on their status as QPs to the estimated burden of continuing H. Stakeholder Input
or Partial QPs. After restricting the the policies the CY 2017 Quality In developing this final rule with
population to eligible clinician types Payment Program final rule, which is comment period, we sought feedback
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who are not newly enrolled, we believe $708 million. We also estimate from stakeholders and the public
the increase in the low-volume regulatory review costs of $2.2 million throughout the process, including in the
threshold is expected to exclude for this final rule with comment period. CY 2018 Quality Payment Program
540,000 clinicians who do not exceed We estimate that federal expenditures proposed rule, CY 2017 Quality
the low-volume threshold. In the 2020 will include $118 million in revenue Payment Program final rule with
MIPS payment year, MIPS payment neutral payment adjustments and $500 comment period, listening sessions,
adjustments will be applied based on million for exceptional performance webinars, and other listening venues.
MIPS eligible clinicians performance payments. Additional federal We received a high degree of interest

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53578 Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations

from a broad spectrum of stakeholders. forward to your feedback on existing or These terms and definitions are
We thank our many commenters and the need for new resources. discussed in detail in relevant sections
acknowledge their valued input of this final rule with comment period.
II. Provisions of the Proposed
throughout the rulemaking process. We C. MIPS Program Details
Regulations, and Analysis of and
summarize and respond to comments on
Responses to Comments 1. MIPS Eligible Clinicians
our proposals in the appropriate
sections of this final rule with comment The following is a summary of the a. Definition of a MIPS Eligible
period, though we are not able to proposed provisions in the Medicare Clinician
address all comments or all issues that Program; CY 2018 Updates to the
all commenters raised due to the Quality Payment Program proposed In the CY 2017 Quality Payment
volume of comments and feedback. rule (82 FR 3001030500) (hereinafter Program final rule (81 FR77040 through
Specifically, due to the volume of referred to as the CY 2018 Quality 77041), we defined at 414.1305 a MIPS
comments we have not summarized Payment Program proposed rule. In eligible clinician, as identified by a
feedback from commenters on items we this section, we also provide summaries unique billing TIN and NPI combination
solicited feedback on for future of the public comments and our used to assess performance, as any of
rulemaking purposes. However, in responses. the following (excluding those
identified at 414.1310(b)): A physician
general, commenters continue to be A. Introduction (as defined in section 1861(r) of the
supportive as we continue
The Quality Payment Program, Act), a physician assistant, nurse
implementation of the Quality Payment
authorized by the Medicare Access and practitioner, and clinical nurse
Program and maintain optimism as we
CHIP Reauthorization Act of 2015 specialist (as such terms are defined in
move from FFS Medicare payment
(MACRA) is a new approach for section 1861(aa)(5) of the Act), a
towards a payment structure focused on
reforming care across the health care certified registered nurse anesthetist (as
the quality and value of care. Public
delivery system for eligible clinicians. defined in section 1861(bb)(2) of the
support for our proposed approach and
Under the Quality Payment Program, Act), and a group that includes such
policies in the proposed rule, which
eligible clinicians can participate via clinicians. We established at
many were finalized, focused on the 414.1310(b) and (c) that the following
potential for improving the quality of one of two pathways: Advanced
Alternative Payment Models (APMs); or are excluded from this definition per the
care delivered to beneficiaries and statutory exclusions defined in section
increasing value to the publicwhile the Merit-based Incentive Payment
System (MIPS). We began implementing 1848(q)(1)(C)(ii) and (v) of the Act: (1)
rewarding eligible clinicians for their QPs; (2) Partial QPs who choose not to
efforts. Additionally we note that we the Quality Payment Program through
rulemaking for calendar year (CY) 2017. report on applicable measures and
received a number of comments from activities that are required to be
stakeholders in regards to the This rule provides updates for the
reported under MIPS for any given
application of MIPS to certain Part B second and future years of the Quality
performance period in a year; (3) low-
drugs. Additional guidance on the Payment Program.
volume threshold eligible clinicians;
applicability of MIPS to Part B drugs B. Definitions and (4) new Medicare-enrolled eligible
can be found on our Web site at clinicians. In accordance with sections
qpp.cms.gov. At 414.1305, subpart O, we define
the following terms: 1848(q)(1)(A) and (q)(1)(C)(vi) of the
We thank stakeholders again for their Act, we established at 414.1310(b)(2)
responses throughout our process, in Ambulatory Surgical Center (ASC)- that eligible clinicians (as defined at
various venues, including comments on based MIPS eligible clinician. 414.1305) who are not MIPS eligible
the Request for Information Regarding CMS Multi-Payer Model. clinicians have the option to voluntarily
Implementation of the Merit-based Facility-based MIPS eligible clinician. report measures and activities for MIPS.
Incentive Payment System, Promotion Full TIN APM. Additionally, we established at
of Alternative Payment Models, and Improvement Scoring. 414.1310(d) that in no case will a
Incentive Payments for Participation in Other MIPS APM. MIPS payment adjustment apply to the
Eligible Alternative Payment Models Solo practitioner. items and services furnished during a
(herein referred to as the MIPS and Virtual group. year by eligible clinicians who are not
APMs RFI) (80 FR 59102 through 59113) We revise the definitions of the MIPS eligible clinicians, as described in
and the CY 2017 Quality Payment following terms: 414.1310(b) and (c), including those
Program final rule (81 FR 77008 through who voluntarily report on applicable
Affiliated practitioner.
77831). We intend to continue open measures and activities specified under
APM Entity.
communication with stakeholders, MIPS.
Attributed beneficiary.
including consultation with tribes and In the CY 2017 Quality Payment
Certified Electronic Health Record
tribal officials, on an ongoing basis as Program final rule (81 FR 77340), we
Technology (CEHRT).
we develop the Quality Payment noted that the MIPS payment
Final Score.
Program in future years. adjustment applies only to the amount
Hospital-based MIPS eligible
We will continue to offer help so otherwise paid under Part B with
clinician.
clinicians can be successful in the respect to items and services furnished
Low-volume threshold.
program and make informed decisions by a MIPS eligible clinician during a
Medicaid APM.
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about how to participate. You can find year, in which we will apply the MIPS
Non-patient facing MIPS eligible
out more about the help thats available payment adjustment at the TIN/NPI
clinician.
at qpp.cms.gov, which has many free level. We have received requests for
Other Payer Advanced APM.
and customized resources, or by calling additional clarifications on which
18662888292. As with the policy Rural areas. specific Part B services are subject to the
decisions, stakeholder feedback is Small practice. MIPS payment adjustment, as well as
essential to the development of We remove the following terms: which Part B services are included for
educational resources as well. We look Advanced APM Entity. eligibility determinations. We note that

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when Part B items or services are permitting groups to split TINs if they occurring in 2018 and future years, we
furnished by suppliers that are also choose to participate in MIPS as a proposed that we would determine the
MIPS eligible clinicians, there may be group. Thus, we would like to clarify size of small practices as described in
circumstances in which it is not that we consider a group to be either an this section of the final rule with
operationally feasible for us to attribute entire single TIN or portion of a TIN comment period (82 FR 30020). As
those items or services to a MIPS that: (1) Is participating in MIPS noted in the CY 2017 Quality Payment
eligible clinician at an NPI level in order according to the generally applicable Program final rule, the size of a group
to include them for purposes of scoring criteria while the remaining (including a small practice) would be
applying the MIPS payment adjustment portion of the TIN is participating in a determined before exclusions are
or making eligibility determinations. MIPS APM or an Advanced APM applied (81 FR 77057). We note that
To further clarify, there are according to the MIPS APM scoring group size determinations are based on
circumstances that involve Part B standard; and (2) chooses to participate the number of NPIs associated with a
prescription drugs and durable medical in MIPS at the group level. We also TIN, which would include eligible
equipment (DME) where the supplier defined an APM Entity group at clinicians (NPIs) who may be excluded
may also be a MIPS eligible clinician. In 414.1305 as a group of eligible from MIPS participation and do not
the case of a MIPS eligible clinician who clinicians participating in an APM meet the definition of a MIPS eligible
furnishes a Part B covered item or Entity, as identified by a combination of clinician.
service, such as prescribing Part B drugs the APM identifier, APM Entity To make eligibility determinations
that are dispensed, administered, and identifier, TIN, and NPI for each regarding the size of small practices for
billed by a supplier that is a MIPS participating eligible clinician. performance periods occurring in 2018
eligible clinician, or ordering DME that and future years, we proposed that we
is administered and billed by a supplier c. Small Practices would determine the size of small
that is a MIPS eligible clinician, it is not In the CY 2017 Quality Payment practices by utilizing claims data (82 FR
operationally feasible for us at this time Program final rule (81 FR 77188), we 30020). For purposes of this section, we
to associate those billed allowed charges defined the term small practices at are coining the term small practice size
with a MIPS eligible clinician at an NPI 414.1305 as practices consisting of 15 determination period to mean a 12-
level in order to include them for or fewer clinicians and solo month assessment period, which
purposes of applying the MIPS payment practitioners. However, it has come to consists of an analysis of claims data
adjustment or making eligibility our attention that there is inconsistency that spans from the last 4 months of a
determinations. To the extent that it is between the proposed definition of a calendar year 2 years prior to the
not operationally feasible for us to do solo practitioner discussed in section performance period followed by the first
so, such items or services would not be II.C.4.b. of this final rule with comment 8 months of the next calendar year and
included for purposes of applying the period and the established definition of includes a 30-day claims run out. This
MIPS payment adjustment or making a small practice. Therefore, to resolve would allow us to inform small
eligibility determinations. However, for this inconsistency and ensure greater practices of their status near the
those billed Medicare Part B allowed consistency with established MIPS beginning of the performance period as
charges that we are able to associate terminology, we are modifying the it pertains to eligibility relating to
with a MIPS eligible clinician at an NPI definition of a small practice at technical assistance, applicable
level, such items and services would be 414.1305 to mean a practice consisting improvement activities criteria, the
included for purposes of applying the of 15 or fewer eligible clinicians. This proposed hardship exception for small
MIPS payment adjustment or making modification is not intended to practices under the advancing care
eligibility determinations. substantively change the definition of a information performance category, and
small practice. In section II.C.4.d. of this the proposed small practice bonus for
b. Groups final rule with comment period, we the final score.
As discussed in the CY 2017 Quality discuss how small practice status would Thus, for purposes of performance
Payment Program final rule (81 FR apply to virtual groups. Also, in the periods occurring in 2018 and the 2020
77088 through 77831), we indicated that final rule with comment period, we MIPS payment year, we would identify
we will assess performance either for noted that we would not make an small practices based on 12 months of
individual MIPS eligible clinicians or eligibility determination regarding the data starting from September 1, 2016 to
for groups. We defined a group at size of small practices, but indicated August 31, 2017. We would not change
414.1305 as a single Taxpayer that small practices would attest to the an eligibility determination regarding
Identification Number (TIN) with two or size of their group practice (81 FR the size of a small practice once the
more eligible clinicians (including at 77057). However, we have since determination is made for a given
least one MIPS eligible clinician), as realized that our system needs to performance period and MIPS payment
identified by their individual NPI, who account for small practice size in year. We recognize that there may be
have reassigned their Medicare billing advance of a performance period for circumstances in which the small
rights to the TIN. We recognize that operational purposes relating to practice size determinations made do
MIPS eligible clinicians participating in assessing and scoring the improvement not reflect the real-time size of such
MIPS may be part of a TIN that has one activities performance category, practices. We considered two options
portion of its NPIs participating in MIPS determining hardship exceptions for that could address such potential
according to the generally applicable small practices, calculating the small discrepancies. One option would
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scoring criteria while the remaining practice bonus for the final score, and include an expansion of the proposed
portion of its NPIs is participating in a identifying small practices eligible for small practice size determination period
MIPS APM or an Advanced APM technical assistance. As a result, we to 24 months with two 12-month
according to the MIPS APM scoring believe it is critical to modify the way segments of data analysis (before and
standard. In the CY 2017 Quality in which small practice size would be during the performance period), in
Payment Program final rule (81 FR determined. To make eligibility which we would conduct a second
77058), we noted that except for groups determinations regarding the size of analysis of claims data during the
containing APM participants, we are not small practices for performance periods performance period. Such an expanded

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determination period may better capture year and includes a 30-day claims run analysis of claims data that spans from
the real-time size of small practices, but out for the small practice size the last 4 months of a calendar year 2
determinations made during the determination. years prior to the performance period
performance period prevent our system Comment: Several commenters followed by the first 8 months of the
from being able to account for the supported the proposal to notify small next calendar year and includes a 30-
assessment and scoring of the practices of their status near the day claims run out for the small practice
improvement activities performance beginning of the performance period so size determination. We anticipate
category and identification of small that practices can plan accordingly. providing MIPS eligible clinicians with
practices eligible for technical Response: We are finalizing that we their small practice size determination
assistance prior to the performance will utilize a 12-month assessment by Spring 2018, for the applicable 2018
period. Specifically, our system needs to period, which consists of an analysis of performance period.
capture small practice determinations in claims data that spans from the last 4 As discussed in the CY 2018 Quality
advance of the performance period in months of a calendar year 2 years prior Payment Program proposed rule (82 FR
order for the system to reflect the to the performance period followed by 30020), there are operational barriers
applicable requirements for the the first 8 months of the next calendar with allowing groups to attest to their
improvement activities performance year and includes a 30-day claims run size. Specifically, since individual MIPS
category and when a small practice out for the small practice size eligible clinicians and groups are not
bonus would be applied. A second determination. We anticipate providing required to register to participate in
option would include an attestation MIPS eligible clinicians with their small MIPS (except for groups utilizing the
component, in which a small practice practice size determination by Spring CMS Web Interface for the Quality
that was not identified as a small 2018, for the applicable 2018 Payment Program or administering the
practice during the small practice size performance period. CAHPS for MIPS survey), requiring
determination period would be able to Comment: Several commenters small practices to attest to the size of
attest to the size of their group practice recommended that practices be allowed their group practice prior to the
prior to the performance period. to attest the size of their practice if they performance period could increase
However, this second option would are not identified during the small burden on individual MIPS eligible
require us to develop several practice size determination period. clinicians and groups. In addition,
operational improvements, such as a Specifically, a few commenters attestation would require us to develop
manual process or system that would expressed concern that utilizing claims several operational improvements, such
provide an attestation mechanism for data will result in practices learning of as a manual process or system that
small practices, and a verification their small practice status too close to would provide an attestation
process to ensure that only small the start of the performance period. A mechanism for small practices, and a
practices are identified as eligible for few commenters recommended that we verification process to ensure that only
technical assistance. Since individual should rely on attestation alone, and small practices are identified as eligible
MIPS eligible clinicians and groups are expressed concern that claims data will for technical assistance. We believe
not required to register to participate in not provide a reliable, real-time utilizing claims data will support most
MIPS (except for groups utilizing the determination of practice size. Another eligibility determinations because we
CMS Web Interface for the Quality commenter specifically recommended consider it a reliable source of how a
Payment Program or administering the that practices be required to attest 180 MIPS eligible clinician or group
CAHPS for MIPS survey), requiring days before the close of the performance interacts with Medicare.
small practices to attest to the size of period so that practices can accurately Comment: One commenter expressed
their group practice prior to the predict their status. One commenter concern that using performance period
performance period could increase recommended that we validate practice data or an attestation portal as a second
burden on individual MIPS eligible size for groups attesting as small using step in the small practice identification
clinicians and groups that are not recent claims data. One commenter process does not provide practices with
already utilizing the CMS Web Interface recommended utilizing a claims adequate advanced notice of their
for the Quality Payment Program or determination process as well as practice size determination and could
administering the CAHPS for MIPS attestation, and using whichever limit their ability to access small
survey. We solicited public comment on method yields a smaller practice size. practice support services.
the proposal regarding how we would Response: Regarding the various Response: We are finalizing that we
determine small practice size. commenters that provided different will utilize a 12-month assessment
The following is a summary of the methods for validating practice size, period, which consists of an analysis of
public comments received on the including: Attesting as small using claims data that spans from the last 4
Small Practices proposal and our recent claims data; utilizing an 180 days months of a calendar year 2 years prior
responses: attestation period; or utilizing a claims to the performance period followed by
Comment: Several commenters determination process as well as the first 8 months of the next calendar
supported using historical claims data attestation, we have considered various year and includes a 30-day claims run
to make a small practice size approaches and have determined that out for the small practice size
determination. One commenter also the most straightforward approach determination. This proposed
noted support for the definition of a which provides the lowest burden to modification of the claims run out
small practice using the number of NPIs MIPS eligible clinicians is the period from 60 days to 30 days increases
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associated with a TIN. utilization of claims data. By utilizing the speed of delivery for communication
Response: We are finalizing that we claims data, we can apply the status of and creation of the file using claims
will utilize a 12-month assessment a small practice accurately without data. In addition, using the 30-day
period, which consists of an analysis of requiring clinicians to take a separate claims run out allows us to inform small
claims data that spans from the last 4 action and attest to being a small practices of their determination as soon
months of a calendar year 2 years prior practice. Therefore, we are finalizing as technically possible, as it pertains to
to the performance period followed by that we will utilize a 12-month eligibility relating to technical
the first 8 months of the next calendar assessment period, which consists of an assistance, applicable improvement

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activities criteria, the proposed hardship MIPS eligible clinicians and eligible rural, using the most recent Health
exception for small practices under the clinicians, such as those in APMs. As Resources and Services Administration
advancing care information performance discussed above, we are modifying the (HRSA) Area Health Resource File data
category, and the proposed small definition of a small practice at set available.
practice bonus for the final score. As a 414.1305 to mean a practice consisting We recognize that there are cases in
result, we do not believe clinicians of 15 or fewer eligible clinicians. This which an individual MIPS eligible
ability to access small practice support modification is not intended to clinician (including a solo practitioner)
services will be limited. substantively change the definition of a or a group may have multiple practice
Comment: A few commenters small practice. In response to the sites associated with its TIN and as a
recommended that we should not allow suggestions that we assess the number result, it is critical for us to outline the
practices to attest that they are small of clinicians at a physical practice site application of rural area and HPSA
practices. Specifically, one commenter to determine small practice status, or practice designations to such practices.
expressed concern that practices may make the small practice assessment For performance periods occurring in
mistakenly expect to be identified as based on the number of full-time 2017, we consider an individual MIPS
small based on their number of MIPS equivalent employees, we acknowledge eligible clinician or a group with at least
eligible clinicians and attest incorrectly. that some practices may be structured in one practice site under its TIN in a ZIP
Response: We acknowledge and agree this manner; however, we do not code designated as a rural area or HPSA
with the commenters concern. We have currently have a reliable method of to be a rural area or HPSA practice. For
considered various approaches and have making a determination that does not performance periods occurring in 2018
determined that the most require a separate action from such and future years, we believe that a
straightforward and best representation practices, such as attestation or higher threshold than one practice
of small practice size determination is submission of supporting
the utilization of claims data. Therefore, within a TIN is necessary to designate
documentation to verify these statuses. an individual MIPS eligible clinician, a
we are finalizing that we will utilize a Rather, we believe the approach of
12-month assessment period, which group, or a virtual group as a rural or
simply counting the NPIs (clinicians) HPSA practice. We recognize that the
consists of an analysis of claims data that are associated with a TIN provides
that spans from the last 4 months of a establishment of a higher threshold
a simple method for all stakeholders to
calendar year 2 years prior to the starting in 2018 would more
understand.
performance period followed by the first appropriately identify groups and
Final Action: After consideration of
8 months of the next calendar year and the public comments, we are finalizing virtual groups with multiple practices
includes a 30-day claims run out for the that we will utilize a 12-month under a groups TIN or TINs that are
small practice size determination. assessment period, which consists of an part of a virtual group as rural or HPSA
Comment: Several commenters did analysis of claims data that spans from practice and ensure that groups and
not support the previously finalized the last 4 months of a calendar year 2 virtual groups are assessed and scored
definition of small practices as practices years prior to the performance period according to requirements that are
consisting of 15 or fewer clinicians and followed by the first 8 months of the applicable and appropriate. We note
solo practitioners. One commenter next calendar year and includes a 30- that in the CY 2017 Quality Payment
recommended that we modify the day claims run out for the small practice Program final rule (81 FR 77048 through
definition of small practices to include size determination. In addition, as 77049), we defined a non-patient facing
those that are similar in challenges and discussed above, we are modifying the MIPS eligible clinician at 414.1305 as
structure, but that may include more definition of a small practice at including a group provided that more
than 15 clinicians. The commenter 414.1305 to mean a practice consisting than 75 percent of the NPIs billing
noted that several small practices may of 15 or fewer eligible clinicians. This under the groups TIN meet the
be loosely tied together under the same modification is not intended to definition of a non-patient facing
TIN but may function as small practices substantively change the definition of a individual MIPS eligible clinician
without the benefit of shared small practice. Finally, we refer readers during the non-patient facing
organizational and administrative to section II.C.4.b. of this final rule with determination period. We refer readers
resources. The commenter comment period for a discussion of the to section II.C.1.e. of this final rule with
recommended that we assess the definition of a solo practitioner. comment period for our policy to
number of clinicians at a physical modify the definition of a non-patient
practice site to determine small practice d. Rural Area and Health Professional facing MIPS eligible clinician. We
status and ability to join a virtual group. Shortage Area Practices believe that using a similar threshold for
Several commenters believed that we In the CY 2017 Quality Payment applying the rural and HPSA
should define small practices based on Program final rule, we defined rural designation to an individual MIPS
the number of MIPS eligible clinicians, areas at 414.1305 as clinicians in ZIP eligible clinician, a group, or virtual
not eligible clinicians. A few codes designated as rural, using the group with multiple practices under its
commenters supported defining small most recent Health Resources and TIN or TINs within a virtual group will
practices based on the number of full- Services Administration (HRSA) Area add consistency for such practices
time equivalent employees, arguing that Health Resource File data set available; across the MIPS as it pertains to groups
rural and HPSAs use different staffing and Health Professional Shortage Areas and virtual groups obtaining such
arrangements to fully staff their (HPSAs) at 414.1305 as areas statuses. We also believe that
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practices. designated under section 332(a)(1)(A) of establishing a 75 percent threshold


Response: Section 1848(q)(2)(B)(iii) of the Public Health Service Act. For renders an adequate representation of a
the Act defines small practices as technical accuracy purposes, we group or virtual group where a
consisting of 15 or fewer professionals. proposed to remove the language significant portion of a group or a
We previously defined small practices clinicians in as clinicians are not virtual group is identified as having
at 414.1305 as practices consisting of technically part of a ZIP code and such status. Therefore, for performance
15 or fewer clinicians and solo modify the definition of a rural areas at periods occurring in 2018 and future
practitioners in order to include both 414.1305 as ZIP codes designated as years, we proposed that an individual

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MIPS eligible clinician, a group, or a appropriately identifies groups and that the 75 percent threshold provides
virtual group with multiple practices virtual groups with multiple practices adequate representation of the group,
under its TIN or TINs within a virtual under a groups TIN or TINs that are and it also aligns with our definition of
group would be designated as a rural or part of a virtual group as rural or HPSA a non-patient facing group, which
HPSA practice if more than 75 percent practices and ensure that groups and provides consistency across the
of NPIs billing under the individual virtual groups are assessed and scored program. We believe rural and HPSA
MIPS eligible clinician or groups TIN or according to requirements that are status should be assigned to groups
within a virtual group, as applicable, are applicable and appropriate. We will because we believe those clinicians that
designated in a ZIP code as a rural area take the suggestions for further analysis are in a rural or HPSA area and choose
or HPSA (82 FR 30020 through 30021). on the characteristics of practices to participate in MIPS as part of a group,
The following is a summary of the currently defined as rural or HPSA to should receive the benefit of those
public comments received on the Rural identify practices that may be statuses, regardless of their chosen
Area and Health Professional Shortage inappropriately classified into participation mechanism. In regards to
Area Practices proposals and our consideration in future rulemaking as the commenter who did not support the
responses: necessary. use of ZIP codes as a reliable indicator
Comment: Several commenters Comment: Several commenters did of rural status due to clinicians
supported the proposals to modify the not support the proposed definition of practicing at multiple sites, we disagree.
definition of rural areas as ZIP codes rural areas and did not support the We believe that utilizing ZIP codes
designated as rural and a rural group proposed group definition of rural and designated as rural is an appropriate
when more than 75 percent of NPIs HPSA practice. One commenter did not indicator of rural status. We further note
billing under the individual MIPS support the use of ZIP codes as a that if a clinician practices at multiple
eligible clinician or groups TIN or reliable indicator of rural status as some sites that have different TINs, each TIN
within a virtual group, as applicable, are clinicians have multiple sites inside and would have a separate rural analysis
designated in a ZIP code as a rural area outside of rural areas. A few applied for that particular site (TIN).
or HPSA. Another commenter commenters recommended that we not Final Action: After consideration of
recommended that we conduct further adopt the policy that a group be the public comments, we are finalizing
analysis on those clinicians who considered rural if more than 75 percent the definition of rural areas at
thought they qualified as a rural area or of NPIs billing under the TIN are 414.1305 as ZIP codes designated as
HPSA practice but did not meet the 75 designated in a ZIP code as rural or rural, using the most recent Health
percent threshold. HPSA because it would overly limit the Resources and Services Administration
Response: We are finalizing that the number of rural group practices. Of (HRSA) Area Health Resource File data
definition of a rural areas at 414.1305 these commenters, two recommended set available. In addition, we are
as ZIP codes designated as rural, using using 50 percent as a threshold, and one finalizing that for performance periods
the most recent Health Resources and commenter recommended a gradual occurring in 2018 and future years, that
Services Administration (HRSA) Area transition using the 2017 threshold for an individual MIPS eligible clinician, a
Health Resource File data set available. the 2018 MIPS performance period and group, or a virtual group with multiple
In addition, we are finalizing that for thresholds of 25 percent, 50 percent, practices under its TIN or TINs within
performance periods occurring in 2018 and 75 percent in performance periods a virtual group would be designated as
and future years, that an individual occurring in 2019, 2020, and 2021, a rural or HPSA practice if more than 75
MIPS eligible clinician, a group, or a respectively. A few commenters percent of NPIs billing under the
virtual group with multiple practices believed that expanding the number of individual MIPS eligible clinician or
under its TIN or TINs within a virtual clinicians in rural or HPSA groups groups TIN or within a virtual group, as
group would be designated as a rural or would hamper the ability of those applicable, are designated in a ZIP code
HPSA practice if more than 75 percent practices to participate fully in the as a rural area or HPSA.
of NPIs billing under the individual transition to value-based care and
MIPS eligible clinician or groups TIN or e. Non-Patient Facing MIPS Eligible
increase disparities between urban and
within a virtual group, as applicable, are Clinicians
rural care. One commenter stated that
designated in a ZIP code as a rural area the status of rural or HPSA should be Section 1848(q)(2)(C)(iv) of the Act
or HPSA. In regard to the suggestion assigned to an individual but not be requires the Secretary, in specifying
that we conduct further analysis on assigned to a group. measures and activities for a
those clinicians who thought they Response: We are finalizing that an performance category, to give
qualified as a rural area or HPSA individual MIPS eligible clinician, a consideration to the circumstances of
practice but did not meet the 75 percent group, or a virtual group with multiple professional types (or subcategories of
threshold, we would encourage those practices under its TIN or TINs within those types determined by practice
stakeholders to contact our Quality a virtual group would be designated as characteristics) who typically furnish
Payment Program Service Center which a rural or HPSA practice if more than 75 services that do not involve face-to-face
may be reached at 18662888292 percent of NPIs billing under the interaction with a patient. To the extent
(TTY 18777156222), available individual MIPS eligible clinician or feasible and appropriate, the Secretary
Monday through Friday, 8:00 a.m.8:00 groups TIN or within a virtual group, as may take those circumstances into
p.m. Eastern Time or via email at QPP@ applicable, are designated in a ZIP code account and apply alternative measures
cms.hhs.gov. as a rural area or HPSA. We do not or activities that fulfill the goals of the
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Comment: One commenter believe establishing a 75 percent applicable performance category to such
recommended we further analyze the threshold would overly limit the non-patient facing MIPS eligible
characteristics of practices currently number of rural group practices, nor clinicians. In carrying out these
defined as rural or HPSA to identify hamper their ability to participate fully provisions, we are required to consult
practices that may be inappropriately in the transition to value-based care, or with non-patient facing MIPS eligible
classified. increase disparities between urban and clinicians.
Response: We believe that rural care. In response to the various In addition, section 1848(q)(5)(F) of
establishing a 75 percent threshold more threshold recommendations, we believe the Act allows the Secretary to re-weight

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MIPS performance categories if there are intend to publish the list of patient- facing determination period is a 24-
not sufficient measures and activities facing encounter codes for performance month assessment period, which
applicable and available to each type of periods occurring in 2018 at includes a two-segment analysis of
MIPS eligible clinician. We assume qpp.cms.gov by the end of 2017. The list claims data regarding patient-facing
many non-patient facing MIPS eligible of patient-facing encounter codes is encounters during an initial 12-month
clinicians will not have sufficient used to determine the non-patient facing period prior to the performance period
measures and activities applicable and status of MIPS eligible clinicians. followed by another 12-month period
available to report under the The list of patient-facing encounter during the performance period. The
performance categories under MIPS. We codes includes two general categories of
initial 12-month segment of the non-
refer readers to section II.C.6.f. of this codes: Evaluation and Management
patient facing determination period
final rule with comment period for the (E&M) codes; and Surgical and
Procedural codes. E&M codes capture spans from the last 4 months of a
discussion regarding how we address
performance category weighting for clinician-patient encounters that occur calendar year 2 years prior to the
MIPS eligible clinicians for whom no in a variety of care settings, including performance period followed by the first
measures or activities are applicable and office or other outpatient settings, 8 months of the next calendar year and
available in a given performance hospital inpatient settings, emergency includes a 60-day claims run out, which
category. departments, and nursing facilities, in allows us to inform individual MIPS
In the CY 2017 Quality Payment which clinicians utilize information eligible clinicians and groups of their
Program final rule (81 FR 77048 through provided by patients regarding history, non-patient facing status during the
77049), we defined a non-patient facing present illness, and symptoms to month (December) prior to the start of
MIPS eligible clinician for MIPS at determine the type of assessments to the performance period. The second 12-
414.1305 as an individual MIPS conduct. Assessments are conducted on month segment of the non-patient facing
eligible clinician that bills 100 or fewer the affected body area(s) or organ determination period spans from the
patient-facing encounters (including system(s) for clinicians to make medical last 4 months of a calendar year 1 year
Medicare telehealth services defined in decisions that establish a diagnosis or prior to the performance period
section 1834(m) of the Act) during the select a management option(s). followed by the first 8 months of the
non-patient facing determination Surgical and Procedural codes capture performance period in the next calendar
period, and a group provided that more clinician-patient encounters that
year and includes a 60-day claims run
than 75 percent of the NPIs billing involve procedures, surgeries, and other
out, which will allow us to inform
under the groups TIN meet the medical services conducted by
clinicians to treat medical conditions. In additional individual MIPS eligible
definition of a non-patient facing
the case of many of these services, clinicians and groups of their non-
individual MIPS eligible clinician
during the non-patient facing evaluation and management work is patient status during the performance
determination period. In order to included in the payment for the single period.
account for the formation of virtual code instead of separately reported. However, based on our analysis of
groups starting in the 2018 performance Patient-facing encounter codes from data from the initial segment of the non-
year and how non-patient facing both of these categories describe direct patient facing determination period for
determinations would apply to virtual services furnished by eligible clinicians performance periods occurring in 2017
groups, we need to modify the with impact on patient safety, quality of (that is, data spanning from September
definition of a non-patient facing MIPS care, and health outcomes. 1, 2015 to August 31, 2016), we found
eligible clinician. Therefore, for For purposes of the non-patient facing that it may not be necessary to include
performance periods occurring in 2018 policies under MIPS, the utilization of
a 60-day claims run out since we could
and future years, we proposed to modify E&M codes and Surgical and Procedural
achieve a similar outcome for such
the definition of a non-patient facing codes allows for accurate identification
of patient-facing encounters, and thus, eligibility determinations by utilizing a
MIPS eligible clinician at 414.1305 to
accurate eligibility determinations 30-day claims run out. In our
mean an individual MIPS eligible
regarding non-patient facing status. As a comparison of data analysis results
clinician that bills 100 or fewer patient-
facing encounters (including Medicare result, MIPS eligible clinicians utilizing a 60-day claims run out versus
telehealth services defined in section considered non-patient facing are able a 30-day claims run out, there was a 1
1834(m) of the Act) during the non- to prepare to meet requirements percent decrease in data completeness
patient facing determination period, and applicable to non-patient facing MIPS (see Table 1 for data completeness
a group or virtual group provided that eligible clinicians. We proposed to regarding comparative analysis of a 60-
more than 75 percent of the NPIs billing continue applying these policies for day and 30-day claims run out). The
under the groups TIN or within a purposes of the 2020 MIPS payment small decrease in data completeness
virtual group, as applicable, meet the year and future years (82 FR 30021). would not negatively impact individual
definition of a non-patient facing As described in the CY 2017 Quality MIPS eligible clinicians or groups
individual MIPS eligible clinician Payment Program final rule, we regarding non-patient facing
during the non-patient facing established the non-patient facing determinations. We believe that a 30-
determination period (82 FR 30021). determination period for purposes of day claims run out would allow us to
We considered a patient-facing identifying non-patient facing MIPS complete the analysis and provide such
encounter to be an instance in which eligible clinicians in advance of the determinations in a more timely
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the individual MIPS eligible clinician or performance period and during the manner.
group billed for items and services performance period using historical and
furnished such as general office visits, performance period claims data. This
outpatient visits, and procedure codes eligibility determination process allows
under the PFS. We published the list of us to begin identifying non-patient
patient-facing encounter codes for facing MIPS eligible clinicians prior to
performance periods occurring in 2017 or shortly after the start of the
at qpp.cms.gov/resources/education. We performance period. The non-patient

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53584 Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations

TABLE 1PERCENTAGES OF DATA to the performance period) to determine more than 75 percent of eligible
COMPLETENESS FOR 60-DAY AND the non-patient facing status of clinicians billing under the group meets
30-DAY CLAIMS RUN OUT individual MIPS eligible clinicians and the individual clinician definition. One
groups, and conduct another eligibility commenter appreciated the flexibility
30-Day determination analysis based on 12
60-Day we are demonstrating in considering the
Incurred year claims months of data (consisting of the last 4
claims use of telehealth. Another commenter
run out * run out *
months of the calendar year prior to the recommended we implement the same
performance period and the first 8 thresholds for rural and HPSA practices.
2015 .................. 97.1% 98.4% months of the performance period) to Response: We are finalizing for
* Note: Completion rates are estimated and determine the non-patient facing status performance periods occurring in 2018
averaged at aggregated service categories of additional individual MIPS eligible and future years that at 414.1305 non-
and may not be applicable to subsets of these clinicians and groups. We would not patient facing MIPS eligible clinician
totals. For example, completion rates can vary
by clinician due to claim processing practices, change the non-patient facing status of means an individual MIPS eligible
service mix, and post payment review activity. any individual MIPS eligible clinician clinician that bills 100 or fewer patient-
Completion rates vary from subsections of a or group identified as non-patient facing facing encounters (including Medicare
calendar year; later portions of a given cal- during the first eligibility determination telehealth services defined in section
endar year will be less complete than earlier 1834(m) of the Act) during the non-
ones. Completion rates vary due to variance in analysis based on the second eligibility
loading patterns due to technical, seasonal, determination analysis. Thus, an patient facing determination period, and
policy, and legislative factors. Completion individual MIPS eligible clinician or a group or virtual group provided that
rates are a function of the incurred date used group that is identified as non-patient more than 75 percent of the NPIs billing
to process claims, and these factors will need facing during the first eligibility under the groups TIN or within a
to be updated if claims are processed on a
claim from date or other methodology. determination analysis would continue virtual group, as applicable, meet the
to be considered non-patient facing for definition of a non-patient facing
For performance periods occurring in the duration of the performance period individual MIPS eligible clinician
2018 and future years, we proposed a and MIPS payment year regardless of during the non-patient facing
modification to the non-patient facing the results of the second eligibility determination period.
determination period, in which the determination analysis. We would Comment: Several commenters did
initial 12-month segment of the non- conduct the second eligibility not support the proposed definition of
patient facing determination period determination analysis to account for non-patient facing as an individual
would span from the last 4 months of a the identification of additional, MIPS eligible clinician that bills 100 or
calendar year 2 years prior to the previously unidentified individual fewer patient-facing encounters during
performance period followed by the first MIPS eligible clinicians and groups that the non-patient facing determination
8 months of the next calendar year and are considered non-patient facing. period, and a group provided that more
include a 30-day claims run out; and the Additionally, in the CY 2017 Quality than 75 percent of the NPIs billing
second 12-month segment of the non- Payment Program final rule (81 FR under the groups TIN meet the
patient facing determination period 77241), we established a policy definition of a non-patient facing
would span from the last 4 months of a regarding the re-weighting of the individual MIPS eligible clinician
calendar year 1 year prior to the advancing care information performance during the non-patient facing
performance period followed by the first category for non-patient facing MIPS determination period. One commenter
8 months of the performance period in eligible clinicians. Specifically, MIPS recommended that the definition of a
the next calendar year and include a 30- eligible clinicians who are considered to non-patient facing clinician be defined
day claims run out (82 FR 30022). The be non-patient facing will have their at the individual clinician level and not
proposal would only change the advancing care information performance be applied at a group level. Another
duration of the claims run out, not the category automatically reweighted to commenter did not support applying the
12-month timeframes used for the first zero (81 FR 77241). For groups that are non-patient facing definition to
and second segments of data analysis. considered to be non-patient facing (that pathologists using PECOS, but rather
For purposes of the 2020 MIPS is, more than 75 percent of the NPIs believed all pathologists should be
payment year, we would initially billing under the groups TIN meet the automatically identified as non-patient
identify individual MIPS eligible definition of a non-patient facing facing.
clinicians and groups who are individual MIPS eligible clinician) Response: We do not agree with the
considered non-patient facing MIPS during the non-patient facing commenters who did not support the
eligible clinicians based on 12 months determination period, we are finalizing proposed definition of a non-patient
of data starting from September 1, 2016, in section II.C.7.b.(3) of this final rule facing MIPS eligible clinician at the
to August 31, 2017. To account for the with comment period to automatically individual or group level. We weighed
identification of additional individual reweight their advancing care several options when considering the
MIPS eligible clinicians and groups that information performance category to appropriate definition of non-patient
may qualify as non-patient facing during zero. We proposed to continue applying facing MIPS eligible clinicians and
performance periods occurring in 2018, these policies for purposes of the 2020 believe we have established an
we would conduct another eligibility MIPS payment year and future years. appropriate threshold that provides the
determination analysis based on 12 The following is a summary of the most appropriate representation of a
months of data starting from September public comments received on the Non- non-patient facing MIPS eligible
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1, 2017, to August 31, 2018. Patient Facing MIPS Eligible Clinicians clinician. The definition of a non-
Similarly, for future years, we would proposals and our responses: patient facing MIPS eligible clinician is
conduct an initial eligibility Comment: Several commenters based on a methodology that would
determination analysis based on 12 supported the policy to define non- allow us to more accurately identify
months of data (consisting of the last 4 patient facing clinicians as individual MIPS eligible clinicians who are non-
months of the calendar year 2 years eligible clinicians billing 100 or fewer patient facing by applying a threshold to
prior to the performance period and the encounters, and group or virtual groups recognize that a MIPS eligible clinician
first 8 months of the calendar year prior to be defined as non-patient facing if who furnishes almost exclusively non-

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patient facing services should be treated timelines. However, we intend to non-patient facing determination
as a non-patient facing MIPS eligible publish the patient-facing codes as close period, and a group or virtual group
clinician despite furnishing a small to when the final rule with comment provided that more than 75 percent of
number of patient-facing services. This period is issued as possible and prior to the NPIs billing under the groups TIN
approach also allows us to determine if the start of the performance period. We or within a virtual group, as applicable,
an individual clinician or a group of will adopt any changes to this policy meet the definition of a non-patient
clinicians is non-patient facing. We through future rulemaking as necessary. facing individual MIPS eligible clinician
believe that having the determination of Comment: Several commenters during the non-patient facing
non-patient facing available at the supported the proposed policy on determination period. In addition, we
individual and group level provides determination periods. The commenters are finalizing that for performance
further flexibilities for MIPS eligible agreed with the proposed policy to use periods occurring in 2018 and future
clinicians on the options available to 2 determination periods. A few years that for purposes of non-patient
them for participation within the commenters recommended that we facing MIPS eligible clinicians, we will
program. Our methodology used to notify MIPS eligible clinicians and utilize E&M codes and Surgical and
identify non-patient facing MIPS groups prior to the start of the Procedural codes for accurate
eligible clinicians included a performance period by either including identification of patient-facing
quantitative, comparative analysis of such information in the MIPS eligibility encounters, and thus, accurate
claims and HCPCS code data. We refer notifications sent to eligible clinicians eligibility determinations regarding non-
commenters to CY 2017 Quality or responding to MIPS eligible clinician patient facing status. Further, we are
Payment Program Final Rule (81 FR or group requests for information. Two finalizing that a patient-facing
77041 through 77049) for a full commenters recommended that we encounter is considered to be an
discussion on the logic for which allow an appeal process or attestation by instance in which the individual MIPS
clinicians are eligible to be non-patient MIPS eligible clinicians for the non- eligible clinician or group billed for
facing MIPS eligible clinicians. We patient facing designation. items and services furnished such as
agree and intend to provide the non- Response: We agree with the general office visits, outpatient visits,
patient facing determination prior to the commenters regarding the non-patient and procedure codes under the PFS.
performance period following the non- facing determination period and that Finally, we are finalizing that for
patient facing determination period as MIPS eligible clinicians should be performance periods occurring in 2018
discussed in section II.C.1.e. of this final notified prior to the performance period and future years, that for the non-patient
rule with comment period. Regarding regarding their eligibility status. In the facing determination period, in which
the comment disagreeing with applying CY 2017 Quality Payment Program final the initial 12-month segment of the non-
the non-patient facing definition to rule (81 FR 77043 through 77048), we patient facing determination period
pathologists using PECOS, we note that established the non-patient facing would span from the last 4 months of a
we are not utilizing PECOS for the non- determination period for purposes of calendar year 2 years prior to the
patient facing determination, rather we identifying non-patient facing MIPS performance period followed by the first
utilize Part B claims data. eligible clinicians in advance of the 8 months of the next calendar year and
Comment: Two commenters performance period and during the include a 30-day claims run out; and the
recommended that we release all performance period using historical and second 12-month segment of the non-
patient-facing codes through formal performance period claims data. In patient facing determination period
notice-and-comment rulemaking rather addition, we would like to note that would span from the last 4 months of a
than subregulatory guidance. MIPS eligible clinicians may access the calendar year 1 year prior to the
Response: In the CY 2018 Quality Quality Payment Program Web site at performance period followed by the first
Payment Program proposed rule (82 FR www.qpp.cms.gov and check if they are 8 months of the performance period in
30021), we noted that we consider a required to submit data to MIPS by the next calendar year and include a 30-
patient-facing encounter to be an entering their NPI into the online tool. day claims run out.
instance in which the individual MIPS In response to the comment regarding
eligible clinician or group billed for appeals for non-patient facing status, if f. MIPS Eligible Clinicians Who Practice
items and services furnished such as a MIPS eligible clinician disagrees with in Critical Access Hospitals Billing
general office visits, outpatient visits, the non-patient facing determination, Under Method II (Method II CAHs)
and procedure codes under the PFS, and we note that clinicians can contact the In the CY 2017 Quality Payment
we described in detail two general Quality Payment Program Service Program final rule (81 FR 77049), we
categories of codes included in this list Center which may be reached at 1866 noted that MIPS eligible clinicians who
of codes, specifically, E&M codes and 2888292 (TTY 18777156222), practice in CAHs that bill under Method
Surgical and Procedural codes, and our available Monday through Friday, 8:00 I (Method I CAHs), the MIPS payment
rationale for including these codes, a.m.-8:00 p.m. Eastern Time or via email adjustment would apply to payments
which we proposed to continue at QPP@cms.hhs.gov. If an error in the made for items and services billed by
applying for purposes of the 2020 MIPS non-patient facing determination is MIPS eligible clinicians, but it would
payment year and future years. discovered, we will update the MIPS not apply to the facility payment to the
Therefore, we do not believe it is eligible clinicians status accordingly. CAH itself. For MIPS eligible clinicians
necessary to specify each individual Final Action: After consideration of who practice in Method II CAHs and
code in notice-and-comment the public comments, we are finalizing have not assigned their billing rights to
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rulemaking. Moreover, we are unable to for performance periods occurring in the CAH, the MIPS payment adjustment
provide the patient-facing codes through 2018 and future years that at 414.1305 would apply in the same manner as for
the notice-and-comment rulemaking as non-patient facing MIPS eligible MIPS eligible clinicians who bill for
the final list of Current Procedural clinician means an individual MIPS items and services in Method I CAHs.
Terminology (CPT) codes used to eligible clinician that bills 100 or fewer As established in the CY 2017 Quality
determine patient facing encounters are patient-facing encounters (including Payment Program final rule (81 FR
often not available in conjunction with Medicare telehealth services defined in 77051), the MIPS payment adjustment
the proposed and final rulemaking section 1834(m) of the Act) during the will apply to Method II CAH payments

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under section 1834(g)(2)(B) of the Act the ASC, HHA, Hospice, or HOPD (1) Individual Identifiers
when MIPS eligible clinicians who methodology would not be subject to As established in the CY 2017 Quality
practice in Method II CAHs have the MIPS payments adjustments (82 FR Payment Program final rule (81 FR
assigned their billing rights to the CAH. 30023). However, these eligible 77058), we define a MIPS eligible
We refer readers to the CY 2017 clinicians have the option to voluntarily clinician at 414.1305 to mean the use
Quality Payment Program final rule (81 report on applicable measures and of a combination of unique billing TIN
FR 77049 through 77051) for our activities for MIPS, in which case the and NPI combination as the identifier to
discussion of MIPS eligible clinicians data received would not be used to assess performance of an individual
who practice in Method II CAHs. assess their performance for the purpose MIPS eligible clinician. Each unique
g. MIPS Eligible Clinicians Who Practice of the MIPS payment adjustment. We TIN/NPI combination is considered a
in Rural Health Clinics (RHCs) or note that eligible clinicians who bill different MIPS eligible clinician, and
Federally Qualified Health Centers under both the PFS and one of these MIPS performance is assessed
(FQHCs) other billing methodologies (ASC, HHA, separately for each TIN under which an
Hospice, and/or HOPD) may be required individual bills.
As established in the CY 2017 Quality
Payment Program final rule (81 FR to participate in MIPS if they exceed the
low-volume threshold and are otherwise (2) Group Identifiers for Performance
77051 through 77053), services
eligible clinicians; in such case, the data As established in the CY 2017 Quality
furnished by an eligible clinician under
reported would be used to determine Payment Program final rule (81 FR
the RHC or FQHC methodology, will not
be subject to the MIPS payments their MIPS payment adjustment. 77059), we codified the definition of a
adjustments. As noted, these eligible The following is a summary of the group at 414.1305 to mean a group that
clinicians have the option to voluntarily public comments received on the MIPS consists of a single TIN with two or
report on applicable measures and Eligible Clinicians Who Practice in more eligible clinicians (including at
activities for MIPS, in which the data ASCs, HHAs, HOPDs proposal and our least one MIPS eligible clinician), as
received will not be used to assess their responses: identified by their individual NPI, who
performance for the purpose of the have reassigned their billing rights to
Comment: A few commenters agreed the TIN.
MIPS payment adjustment. with the proposal that services
We refer readers to the CY 2017 (3) APM Entity Group Identifiers for
furnished by an eligible clinician that
Quality Payment Program final rule (81 Performance
are payable under the ASC, HHA,
FR 77051 through 77053) for our
Hospice, or Outpatient payment As described in the CY 2017 Quality
discussion of MIPS eligible clinicians
methodology would not be subject to Payment Program final rule (81 FR
who practice in RHCs or FQHCs.
the MIPS payment adjustments. 77060), we established that each eligible
h. MIPS Eligible Clinicians Who Response: We appreciate the clinician who is a participant of an APM
Practice in Ambulatory Surgical Centers commenters support. We are finalizing Entity is identified by a unique APM
(ASCs), Home Health Agencies (HHAs), that services furnished by an eligible participant identifier. The unique APM
Hospice, and Hospital Outpatient clinician that are payable under the participant identifier is a combination of
Departments (HOPDs) ASC, HHA, Hospice, or HOPD four identifiers: (1) APM Identifier
Section 1848(q)(6)(E) of the Act methodology will not be subject to the (established by CMS; for example,
provides that the MIPS payment MIPS payments adjustments and that XXXXXX); (2) APM Entity identifier
adjustment is applied to the amount such data will not be utilized for MIPS (established under the APM by CMS; for
otherwise paid under Part B with eligibility purposes. example, AA00001111); (3) TIN(s) (9
respect to the items and services numeric characters; for example,
Final Action: After consideration of XXXXXXXXX); (4) EP NPI (10 numeric
furnished by a MIPS eligible clinician
the public comments, we are finalizing characters; for example, 1111111111).
during a year. Some eligible clinicians
that services furnished by an eligible We codified the definition of an APM
may not receive MIPS payment
clinician that are payable under the Entity group at 414.1305 to mean a
adjustments due to their billing
ASC, HHA, Hospice, or HOPD group of eligible clinicians participating
methodologies. If a MIPS eligible
methodology will not be subject to the in an APM Entity, as identified by a
clinician furnishes items and services in
MIPS payments adjustments and that combination of the APM identifier,
an ASC, HHA, Hospice, and/or HOPD
such data will not be utilized for MIPS APM Entity identifier, TIN, and NPI for
and the facility bills for those items and
eligibility purposes, as proposed. each participating eligible clinician.
services (including prescription drugs)
under the facilitys all-inclusive i. MIPS Eligible Clinician Identifiers 2. Exclusions
payment methodology or prospective
payment system methodology, the MIPS As described in the CY 2017 Quality a. New Medicare-Enrolled Eligible
adjustment would not apply to the Payment Program final rule (81 FR Clinician
facility payment itself. However, if a 77057), we established the use of As established in the CY 2017 Quality
MIPS eligible clinician furnishes other multiple identifiers that allow MIPS Payment Program final rule (81 FR
items and services in an ASC, HHA, eligible clinicians to be measured as an 77061 through 77062), we defined a
Hospice, and/or HOPD and bills for individual or collectively through a new Medicare-enrolled eligible clinician
those items and services separately, groups performance and that the same at 414.1305 as a professional who first
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such as under the PFS, the MIPS identifier be used for all four becomes a Medicare-enrolled eligible
adjustment would apply to payments performance categories. While we have clinician within the PECOS during the
made for such items and services. Such multiple identifiers for participation performance period for a year and had
items and services would also be and performance, we established the use not previously submitted claims under
considered for purposes of applying the of a single identifier, TIN/NPI, for Medicare such as an individual, an
low-volume threshold. Therefore, we applying the MIPS payment adjustment, entity, or a part of a clinician group or
proposed that services furnished by an regardless of how the MIPS eligible under a different billing number or tax
eligible clinician that are payable under clinician is assessed. identifier. Additionally, we established

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at 414.1310(c) that these eligible In the CY 2017 Quality Payment outcomes, co-morbidities, chronic
clinicians will not be treated as a MIPS Program final rule (81 FR 77069 through conditions, and other social risk factors,
eligible clinician until the subsequent 77070), we defined MIPS eligible which can result in the costs of
year and the performance period for clinicians or groups who do not exceed providing care and services being
such subsequent year. We established at the low-volume threshold at 414.1305 significantly higher compared to non-
414.1310(d) that in no case would a as an individual MIPS eligible clinician rural areas. We also have heard from
MIPS payment adjustment apply to the or group who, during the low-volume many solo practitioners and small
items and services furnished during a threshold determination period, has practices that still face challenges and
year by new Medicare-enrolled eligible Medicare Part B allowed charges less additional resource burden in
clinicians for the applicable than or equal to $30,000 or provides participating in the MIPS.
performance period. care for 100 or fewer Part B-enrolled In the CY 2017 Quality Payment
We used the term new Medicare- Medicare beneficiaries. We established Program final rule, we did not establish
enrolled eligible clinician determination at 414.1310(b) that for a year, eligible an adjustment for social risk factors in
period to refer to the 12 months of a clinicians who do not exceed the low- assessing and scoring performance. In
calendar year applicable to the volume threshold (as defined at response to the CY 2017 Quality
performance period. During the new 414.1305) are excluded from MIPS for Payment Program final rule, we received
Medicare-enrolled eligible clinician the performance period for a given public comments indicating that
determination period, we conduct calendar year. individual MIPS eligible clinicians and
eligibility determinations on a quarterly In the CY 2017 Quality Payment groups practicing in designated rural
basis to the extent that is technically Program final rule (81 FR 77069 through areas would be negatively impacted and
feasible to identify new Medicare- 77070), we defined the low-volume at a disadvantage if assessment and
enrolled eligible clinicians that would threshold determination period to mean scoring methodology did not adjust for
be excluded from the requirement to a 24-month assessment period, which social risk factors. Additionally,
participate in MIPS for the applicable includes a two-segment analysis of commenters expressed concern that
performance period. claims data during an initial 12-month such individual MIPS eligible clinicians
period prior to the performance period and groups may be disproportionately
b. Qualifying APM Participant (QP) and
followed by another 12-month period more susceptible to lower performance
Partial Qualifying APM Participant
during the performance period. The scores across all performance categories
(Partial QP)
initial 12-month segment of the low- and negative MIPS payments
In the CY 2017 Quality Payment volume threshold determination period adjustments, and as a result, such
Program final rule (81 FR 77062), we spans from the last 4 months of a outcomes may further strain already
established at 414.1305 that a QP (as calendar year 2 years prior to the limited fiscal resources and workforce
defined at 414.1305) is not a MIPS performance period followed by the first shortages, and negatively impact access
eligible clinician, and therefore, is 8 months of the next calendar year and to care (reduction and/or elimination of
excluded from MIPS. Also, we includes a 60-day claims run out, which available services).
established that a Partial QP (as defined allows us to inform eligible clinicians After the consideration of stakeholder
at 414.1305) who does not report on and groups of their low-volume status feedback, we proposed to modify the
applicable measures and activities that during the month (December) prior to low-volume threshold policy
are required to be reported under MIPS the start of the performance period. The established in the CY 2017 Quality
for any given performance period in a second 12-month segment of the low- Payment Program final rule (82 FR
year is not a MIPS eligible clinician, and volume threshold determination period 30024). We stated that we believe that
therefore, is excluded from MIPS. spans from the last 4 months of a increasing the dollar amount and
c. Low-Volume Threshold calendar year 1 year prior to the beneficiary count of the low-volume
performance period followed by the first threshold would further reduce the
Section 1848(q)(1)(C)(ii)(III) of the Act 8 months of the performance period in number of eligible clinicians that are
provides that the definition of a MIPS the next calendar year and includes a required to participate in the MIPS,
eligible clinician does not include 60-day claims run out, which allows us which would reduce the burden on
eligible clinicians who are below the to inform additional eligible clinicians individual MIPS eligible clinicians and
low-volume threshold selected by the and groups of their low-volume status groups practicing in small practices and
Secretary under section 1848(q)(1)(C)(iv) during the performance period. designated rural areas. Based on our
of the Act for a given year. Section We recognize that individual MIPS analysis of claims data, we found that
1848(q)(1)(C)(iv) of the Act requires the eligible clinicians and groups that are increasing the low-volume threshold to
Secretary to select a low-volume small practices or practicing in exclude individual eligible clinicians or
threshold to apply for the purposes of designated rural areas face unique groups that have Medicare Part B
this exclusion which may include one dynamics and challenges such as fiscal allowed charges less than or equal to
or more of the following: (1) The limitations and workforce shortages, but $90,000 or that provide care for 200 or
minimum number, as determined by the serve as a critical access point for care fewer Part B-enrolled Medicare
Secretary, of Part B-enrolled individuals and provide a safety net for vulnerable beneficiaries will exclude
who are treated by the eligible clinician populations. Claims data shows that approximately 134,000 additional
for a particular performance period; (2) approximately 15 percent of individual clinicians from MIPS from the
the minimum number, as determined by MIPS eligible clinicians (TIN/NPIs) are approximately 700,000 clinicians that
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the Secretary, of items and services considered to be practicing in rural would have been eligible based on the
furnished to Part B-enrolled individuals areas after applying all exclusions. Also, low-volume threshold that was finalized
by the eligible clinician for a particular we have heard from stakeholders that in the CY 2017 Quality Payment
performance period; and (3) the MIPS eligible clinicians practicing in Program final rule. Almost half of the
minimum amount, as determined by the small practices and designated rural additionally excluded clinicians are in
Secretary, of allowed charges billed by areas tend to have a patient population small practices, and approximately 17
the eligible clinician for a particular with a higher proportion of older adults, percent are clinicians from practices in
performance period. as well as higher rates of poor health designated rural areas. Applying this

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criterion decreases the percentage of the clinicians and groups who face the last 4 months of a calendar year 2
MIPS eligible clinicians that come from additional participation burden while years prior to the performance period
small practices. For example, prior to not excluding a significant portion of followed by the first 8 months of the
any exclusions, clinicians in small the clinician population. next calendar year and include a 30-day
practices represent 35 percent of all Eligible clinicians who do not exceed claims run out; and the second 12-
clinicians billing Part B services. After the low-volume threshold (as defined at month segment of the low-volume
applying the eligibility criteria for the 414.1305) are excluded from MIPS for threshold determination period would
CY 2017 Quality Payment Program final the performance period with respect to span from the last 4 months of a
rule, MIPS eligible clinicians in small a year. The low-volume threshold also calendar year 1 year prior to the
practices represent approximately 27 applies to eligible clinicians who performance period followed by the first
percent of the clinicians eligible for practice in APMs under the APM 8 months of the performance period in
MIPS; however, with the increased low- scoring standard at the APM Entity the next calendar year and include a 30-
volume threshold, approximately 22 level, in which APM Entities do not day claims run out (82 FR 30025). We
percent of the clinicians eligible for exceed the low-volume threshold. In stated that the proposal would only
MIPS are from small practices. In our such cases, the eligible clinicians change the duration of the claims run
analysis, the proposed changes to the participating in the MIPS APM Entity out, not the 12-month timeframes used
low-volume threshold showed little would be excluded from the MIPS for the first and second segments of data
impact on MIPS eligible clinicians from requirements for the applicable analysis.
practices in designated rural areas. performance period and not subject to a For purposes of the 2020 MIPS
MIPS eligible clinicians from practices MIPS payment adjustment for the payment year, we would initially
in designated rural areas account for15 applicable year. Such an exclusion identify individual eligible clinicians
to 16 percent of the total MIPS eligible would not affect an APM Entitys QP and groups that do not exceed the low-
clinician population. We note that, due determination if the APM Entity is an volume threshold based on 12 months
to data limitations, we assessed rural Advanced APM. of data starting from September 1, 2016
status based on the status of individual In the CY 2017 Quality Payment to August 31, 2017. To account for the
TIN/NPI and did not model any group Program final rule, we established the identification of additional individual
definition for practices in designated low-volume threshold determination eligible clinicians and groups that do
rural areas. period to refer to the timeframe used to not exceed the low-volume threshold
We believe that increasing the number assess claims data for making eligibility during performance periods occurring
of such individual eligible clinicians determinations for the low-volume in 2018, we would conduct another
and groups excluded from MIPS threshold exclusion (81 FR 77069 eligibility determination analysis based
participation would reduce burden and through 77070). We defined the low- on 12 months of data starting from
mitigate, to the extent feasible, the issue volume threshold determination period September 1, 2017 to August 31, 2018.
surrounding confounding variables to mean a 24-month assessment period, We would not change the low-volume
impacting performance under the MIPS. which includes a two-segment analysis status of any individual eligible
Therefore, beginning with the 2018 of claims data during an initial 12- clinician or group identified as not
MIPS performance period, we proposed month period prior to the performance exceeding the low-volume threshold
to increase the low-volume threshold. period followed by another 12-month during the first eligibility determination
Specifically, at 414.1305, we proposed period during the performance period. analysis based on the second eligibility
to define an individual MIPS eligible Based on our analysis of data from the determination analysis. Thus, an
clinician or group who does not exceed initial segment of the low-volume individual eligible clinician or group
the low-volume threshold as an threshold determination period for that is identified as not exceeding the
individual MIPS eligible clinician or performance periods occurring in 2017 low-volume threshold during the first
group who, during the low-volume (that is, data spanning from September eligibility determination analysis would
threshold determination period, has 1, 2015 to August 31, 2016), we found continue to be excluded from MIPS for
Medicare Part B allowed charges less that it may not be necessary to include the duration of the performance period
than or equal to $90,000 or provides a 60-day claims run out since we could regardless of the results of the second
care for 200 or fewer Part B-enrolled achieve a similar outcome for such eligibility determination analysis. We
Medicare beneficiaries. This would eligibility determinations by utilizing a established our policy to include two
mean that approximately 37 percent of 30-day claims run out. eligibility determination analyses in
individual eligible clinicians and groups In our comparison of data analysis order to prevent any potential confusion
would be eligible for MIPS based on the results utilizing a 60-day claims run out for an individual eligible clinician or
low-volume threshold exclusion (and versus a 30-day claims run out, there group to know whether or not
the other exclusions). However, was a 1 percent decrease in data participate in MIPS; also, such policy
approximately 65 percent of Medicare completeness. The small decrease in makes it clear from the onset as to
payments would still be captured under data completeness would not which individual eligible clinicians and
MIPS as compared to 72.2 percent of substantially impact individual MIPS groups would be required to participate
Medicare payments under the CY 2017 eligible clinicians or groups regarding in MIPS. We would conduct the second
Quality Payment Program final rule. low-volume threshold determinations. eligibility determination analysis to
We recognize that increasing the We believe that a 30-day claims run out account for the identification of
dollar amount and beneficiary count of would allow us to complete the analysis additional, previously unidentified
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the low-volume threshold would and provide such determinations in a individual eligible clinicians and groups
increase the number of individual more timely manner. For performance who do not exceed the low-volume
eligible clinicians and groups excluded periods occurring in 2018 and future threshold. We note that low-volume
from MIPS. We assessed various levels years, we proposed a modification to the threshold determinations are made at
of increases and found that $90,000 as low-volume threshold determination the individual and group level, and not
the dollar amount and 200 as the period, in which the initial 12-month at the virtual group level.
beneficiary count balances the need to segment of the low-volume threshold As noted above, section
account for individual eligible determination period would span from 1848(q)(1)(C)(iv) of the Act requires the

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Secretary to select a low-volume opt-in to MIPS participation if they The following is a summary of the
threshold to apply for the purposes of might otherwise be excluded under the public comments received on the Low-
this exclusion which may include one low-volume threshold, such as where Volume Threshold proposals and our
or more of the following: (1) The they only meet one of the threshold responses:
minimum number, as determined by the determinations (including a third Comment: Many commenters
Secretary, of Part B-enrolled individuals determination based on Part B items and supported raising the low-volume
who are treated by the eligible clinician services, if established). For example, if threshold to exclude an individual
for a particular performance period; (2) a clinician meets the low-volume MIPS eligible clinician or group who,
the minimum number, as determined by threshold of $90,000 in allowed charges, during the low-volume threshold
the Secretary, of items and services but does not meet the threshold of 200 determination period, has Medicare Part
furnished to Part B-enrolled individuals patients or, if established, the threshold B allowed charges less than or equal to
by the eligible clinician for a particular pertaining to Part B items and services, $90,000 or provides care for 200 or
performance period; and (3) the we believe the clinician should, to the fewer Part B-enrolled Medicare
minimum amount, as determined by the extent feasible, have the opportunity to beneficiaries. Several commenters
Secretary, of allowed charges billed by choose whether or not to participate in further suggested that we retroactively
the eligible clinician for a particular the MIPS and be subject to MIPS apply the threshold to the 2017 MIPS
performance period. We have payment adjustments. We recognize that performance period because changing
established a low-volume threshold that this choice would present additional the low-volume threshold for the 2018
accounts for the minimum number of complexity to clinicians in MIPS performance period would create
Part-B enrolled individuals who are understanding all of their available confusion, complicate operational and
treated by an eligible clinician and that options and may impose additional strategic planning for eligible clinicians,
accounts for the minimum amount of burden on clinicians by requiring them and create inefficiencies for clinicians.
allowed charges billed by an eligible to notify us of their decision. Because of One commenter noted that we has not
clinician. We did not make proposals these concerns and our desire to yet issued the required second round of
specific to a minimum number of items establish options in a way that is a low- reports notifying MIPS eligible
and service furnished to Part-B enrolled burden and user-focused experience for clinicians whether they are below the
individuals by an eligible clinician. all MIPS eligible clinicians, we would low-volume threshold, so it would be
In order to expand the ways in which not be able to offer this additional technically feasible to implement the
claims data could be analyzed for flexibility until performance periods lower threshold before the end of the CY
purposes of determining a more occurring in 2019. Therefore, as a means 2017 reporting period. A few
comprehensive assessment of the low- of expanding options for clinicians and commenters supported the proposal but
volume threshold, we have assessed the offering them the ability to participate recommended that we maintain the
option of establishing a low-volume in MIPS if they otherwise would not be current, lower low-volume threshold for
threshold for items and services included, for the purposes of the 2021 at least 2, 3, or more years to allow for
furnished to Part-B enrolled individuals MIPS payment year, we proposed to planning and investment by clinicians
by an eligible clinician. We have provide clinicians the ability to opt-in to in the program.
considered defining items and services Response: We appreciate the support
the MIPS if they meet or exceed one, but
by using the number of patient from commenters who supported raising
not all, of the low-volume threshold
encounters or procedures associated the low-volume threshold. We are
determinations, including as defined by
with a clinician. Defining items and finalizing our proposal to define at
dollar amount, beneficiary count or, if
services by patient encounters would 414.1305 an individual eligible
established, items and services (82 FR clinician or group that does not exceed
assess each patient per visit or
30026). the low-volume threshold as an
encounter with the eligible clinician.
We believe that defining items and We note that there may be additional individual eligible clinician or group
services by using the number of patient considerations we should address for that, during the low-volume threshold
encounters or procedures is a simple scenarios in which an individual determination period, has Medicare Part
and straightforward approach for eligible clinician or a group does not B allowed charges less than or equal to
stakeholders to understand. However, exceed the low-volume threshold and $90,000 or provides care for 200 or
we are concerned that using this unit of opts-in to participate in MIPS. We fewer Part B-enrolled Medicare
analysis could incentivize clinicians to therefore sought comment on any beneficiaries. We do not believe that we
focus on volume of services rather than additional considerations we should have the flexibility to retroactively
the value of services provided to address when establishing this opt-in apply the revised low-volume threshold
patients. Defining items and services by policy. Additionally, we note that there to the 2017 MIPS performance period
procedure would tie a specific clinical is the potential with this opt-in policy threshold. We are aware that by
procedure furnished to a patient to a for there to be an impact on our ability finalizing this policy, some MIPS
clinician. We solicited public comment to create quality benchmarks that meet eligible clinicians who were eligible to
on the methods of defining items and our sample size requirements. For participate in MIPS for Year 1 will be
services furnished by clinicians example, if particularly small practices excluded for Year 2. However, we
described in this paragraph above and or solo practitioners with low Part B would like to note that those MIPS
alternate methods of defining items and beneficiary volumes opt-in, such eligible clinicians may still participate
services (82 FR 30025 through 30026). clinicians may lack sufficient sample in Year 1. Finally, we agree with the
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For the individual eligible clinicians size to be scored on many quality commenter that there are benefits of
and groups that would be excluded from measures, especially measures that do maintaining the same low-volume
MIPS participation as a result of an not apply to all of a MIPS eligible threshold for several years and will take
increased low-volume threshold, we clinicians patients. We therefore sought this into consideration in future years.
believe that in future years it would be comment on how to address any Comment: Several commenters did
beneficial to provide, to the extent potential impact on our ability to create not support the proposed low-volume
feasible, such individual eligible quality benchmarks that meet our threshold because the commenters
clinicians and groups with the option to sample size requirements (82 FR 30026). believed the low-volume threshold

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53590 Federal Register / Vol. 82, No. 220 / Thursday, November 16, 2017 / Rules and Regulations

should be raised further to exclude more that we are not focused on transitioning will not be required to participate in the
clinicians. Several of those commenters to value-based payment and care. A few Quality Payment Program; however, we
specifically recommended that we set commenters expressed concern that still encourage all clinicians to provide
the threshold no lower than $100,000 in raising the low-volume threshold would high-value care to their patients. The
Medicare Part B charges and to only create further disparities in quality goal of raising the low-volume threshold
apply to practices with 10 or fewer between urban and rural clinicians is to reduce burden on small practices,
eligible clinicians. based on the reduced incentives for and we do not believe it will create a
Response: We disagree with the rural clinicians to participate in value- 2-tiered system. We appreciate the
commenters regarding raising the low- based purchasing programs. One of suggestion to study the impact on the
volume threshold further. Based on our these commenters strongly rural health industry before finalizing
data analysis, applying the proposed recommended that we study the impact this policy. We do not believe a study
criterion decreases the percentage of on the rural health industry prior to is necessary prior to finalizing this
MIPS eligible clinicians that come from implementing the increased low-volume policy; rather, we believe that there is
small practices. We note that from our threshold. Many commenters noted that sufficient evidence from stakeholder
updated data models we found that the excluding more clinicians would risk feedback to reflect the value of
revised low-volume threshold will dismantling the EHR infrastructure that increasing the low-volume threshold at
exclude approximately 123,000 has developed over recent years as this time. We do not agree that this
additional clinicians from MIPS from additional practices opt-out of policy would risk dismantling the EHR
the approximately 744,000 clinicians participation in programs designed to infrastructure. We believe that the low-
that would have been eligible based on increase adoption and use of EHRs, volume threshold in Year 2 provides
the low-volume threshold that was wasting the billions of dollars we have MIPS eligible clinicians and groups,
finalized in the CY 2017 Quality invested to date in EHRs. The particularly those in smaller practices
Payment Program final rule. We believe commenters believed that reduction in and rural areas, that do not exceed the
that if we were to raise the low-volume use of EHRs will affect participating low-volume threshold with additional
threshold further, we may prevent clinicians as well by hampering time to further invest in their EHR
medium size practices that wish to connectivity and information sharing infrastructure to gain experience in
participate from the opportunity to between excluded clinicians and implementing and utilizing an EHR
receive an upward adjustment and participating clinicians. Some infrastructure to meet their needs and
would have fewer clinicians engaged in commenters also stated that decreased prepare for their potential participation
value-based care. We believe the investment in EHRs by excluded in MIPS in future years while not being
finalized low-volume threshold strikes clinicians will drive greater disparities subject to the possibility of a negative
the appropriate balance with the need to in care quality between clinicians who payment adjustment. We believe that
account for individual MIPS eligible are engaged in value-based purchasing clinicians and patients benefit from the
clinicians and groups who face and those who are not. One commenter utilization and capabilities of an EHR
additional participation burden while strongly recommended that we delay infrastructure and would continue to
not excluding a significant portion of implementation of the proposed low- utilize this technology. In addition, we
the clinician population. We are volume threshold. Another commenter do not believe we should delay
finalizing the low-volume threshold to recommended that, rather than exclude implementation of this policy as it
exclude an individual eligible clinician clinicians from MIPS, we should allow reduces the burden on individual MIPS
or group that, during the low-volume eligible clinicians and those in small
clinicians to continue the pick-your-
threshold determination period, has
pace approach and continue practices and in some rural areas. The
Medicare Part B allowed charges less
participating in MIPS. intention of the Year 1 pick-your-pace
than or equal to $90,000 or provides
Response: We acknowledge there will policies were to set the foundation for
care for 200 or fewer Part B-enrolled
be MIPS eligible clinicians who were MIPS to support long-term, high quality
Medicare beneficiaries.
Comment: Many commenters did not eligible for Year 1 of MIPS that are no patient care through feedback by
support raising the low-volume longer eligible for Year 2 of MIPS. lowering the barriers to participation.
threshold for the 2018 MIPS However, from our analyses, the MIPS Year 2 continues this transition as we
performance period because they eligible clinicians affected are mainly are providing a gradual ramp-up of the
believed it would be unfair to clinicians smaller practices and practices in rural program and of the performance
who were already participating or areas, many of which have raised thresholds. For the low-volume
planned to participate in MIPS in future concerns regarding their ability to threshold, we are finalizing our
years. The commenters noted that participate in MIPS. We want to proposal to increase the threshold,
clinicians may have already invested in encourage all clinicians to participate in which excludes more eligible clinicians
MIPS participation. Many commenters value-based care within the MIPS; from MIPS. Specifically, we are
did not support the proposed low- however, we have continued to hear finalizing our proposal to exclude an
volume threshold because they believed from practices that challenges to individual eligible clinician or group
that raising the low-volume threshold participation in the Quality Payment that, during the low-volume threshold
would reduce payment and incentives Program still exist. Therefore, we determination period, has Medicare Part
for excluded clinicians to participate in believe it is appropriate to raise the low- B allowed charges less than or equal to
value-based care, which would create volume threshold to not require these $90,000 or provides care for 200 or
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additional quality and reimbursement practices to participate in the program. fewer Part B-enrolled Medicare
disparities for the beneficiaries seen by However, we will review the impacts of beneficiaries.
the excluded clinicians, creating a this policy to determine if it should Comment: Many commenters did not
2-tiered system of clinicians and related remain. We do not believe that raising support the proposed low-volume
beneficiaries that are participating in the low-volume threshold will cause threshold because it is based on the
value-based care. The commenters quality disparities between urban and amount of Medicare billings from
noted that raising the low-volume rural practices. With the increased low- clinicians or number of beneficiaries.
threshold would signal to the industry volume threshold, additional practices Instead, the commenters offered

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recommendations for alternative ways Response: We note that some of the at the group level that exceeds the low-
of applying the low-volume threshold. suggestions provided are not compliant volume threshold. In the CY 2017
Many commenters recommended that with the statute, specifically, the Quality Payment Program final rule (82
we exclude all practices with 15 or suggestions on basing the low-volume FR 77071) we considered aligning how
fewer clinicians. Several commenters threshold exclusion on practice size, MIPS exclusions would be applied at
recommended redefining the low- practice location and specialty the group level. We recognized that
volume threshold so that it would characteristics. We note that section alignment would provide a uniform
mirror the policy for non-patient facing 1848(q)(1)(C)(iv) of the Act requires the application across exclusions and offer
eligible clinicians by excluding a group Secretary to select a low-volume simplicity, but we also believed that it
from MIPS if 75 percent or more of its threshold to apply for the purposes of is critical to ensure that there are
eligible clinicians individually fall this exclusion which may include one opportunities encouraging coordination,
below the low-volume threshold or if or more of the following: (1) The teamwork, and shared responsibility
the groups average Medicare allowed minimum number, as determined by the within groups. In order to encourage
charges or Medicare patient population Secretary, of Part B-enrolled individuals coordination, teamwork, and shared
falls below the threshold. The who are treated by the eligible clinician responsibility at the group level, we
for a particular performance period; (2) finalized that we would assess the low-
commenters noted that this would align
the minimum number, as determined by volume threshold so that all clinicians
status determinations across the Quality
the Secretary, of items and services within the group have the same status:
Payment Program and reduce
furnished to Part B-enrolled individuals all clinicians collectively exceed the
complexity and burden. One commenter low-volume threshold or they do not
recommended excluding: Practices with by the eligible clinician for a particular
performance period; and (3) the exceed the low-volume threshold. We
less than $100,000 per clinician in appreciate the other concerns and
Medicare charges not including Part B minimum amount, as determined by the
Secretary, of allowed charges billed by recommendations provided by the
drug costs; practices with 10 or fewer commenters. We received a range of
the eligible clinician for a particular
clinicians; and rural clinicians suggestions and considered the various
performance period. We do not believe
practicing in an area with fewer than options. We are finalizing our proposal
the statute provides discretion in
100 clinicians per 100,000 population. to exclude an individual MIPS eligible
establishing exclusions other than the
The commenter further encouraged us clinician or group that, during the low-
three exclusions specified above.
to consider excluding specialists who Additionally, for the commenters volume threshold determination period,
practice in ZIP codes or other suggestion to use a percentage of has Medicare Part B allowed charges
geographic areas with low per capita Medicare charges to total charges and a less than or equal to $90,000 or provides
numbers of clinicians in their specialty percentage of Medicare patients to total care for 200 or fewer Part B-enrolled
per population. One commenter patients as opposed to the use of a Medicare beneficiaries. In this final rule
recommended that we establish 2 minimum number of claims and with comment period, we are requesting
different low-volume thresholds for patients, we will take this suggestion additional comments regarding the
primary care and specialty care under consideration for future application of low-volume threshold at
clinicians. Another commenter rulemaking. In regards to the the group level.
recommended using a percentage of commenters suggestion to exclude all Comment: Many commenters
Medicare charges to total charges and a supported the proposed policy to
clinicians from MIPS that have non-
percentage of Medicare patients to total provide clinicians the ability to opt-in to
participation status within Medicare, we
patients as opposed to the use of claims the MIPS if they meet or exceed one, but
note that these clinicians may still fall
and patients. One commenter noted that not all, of the low-volume threshold
within the definition of a MIPS eligible
the low-volume thresholds inclusion of determinations, including as defined by
clinician at 414.1305. However, as
beneficiaries creates an incentive for dollar amount, beneficiary count, or, if
provided in 414.1310(d), in no case
clinicians to turn away Medicare established, items and services
will a MIPS payment adjustment apply
beneficiaries in order to fall below the beginning with the 2019 MIPS
to the items and services furnished
low-volume threshold. Another performance period. Other commenters
during a year by clinicians who are not
supported applying the opt-in based on
commenter recommended that we MIPS eligible clinicians. the Medicare Part B charges criterion,
exclude all clinicians who have elected We note that the low-volume but not the Medicare beneficiary
to have non-participation status for threshold is different from the other criterion. Several commenters
Medicare. As an alternative to raising exclusions in that it is not determined supported the proposal to allow opt-in
the low-volume threshold, one solely based on the individual NPI but requested that the policy be
commenter recommended that we status, it is based on both the TIN/NPI retroactively applied to the 2017 MIPS
reduce the reporting requirement for (to determine an exclusion at the performance period. A few commenters
small practices or for those practices individual level) and TIN (to determine supported the proposed opt-in option
between the previous threshold of an exclusion at the group level) status. but recommended that we establish
$30,000 and 100 beneficiaries to In regard to group-level reporting, the separate performance benchmarks for
$90,000 and 200 beneficiaries. Several group, as a whole, is assessed to excluded individuals or groups that opt-
commenters specifically did not support determine if the group (TIN) exceeds the in. Other commenters recommended
that a group could meet the low-volume low-volume threshold. Thus, eligible that we shield opt-in clinicians so that
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threshold based on services provided by clinicians (TIN/NPI) who do not exceed they can avoid a negative payment
a small percentage of the clinicians in the low-volume threshold at the adjustment or other disadvantages of
the group. A few commenters individual reporting level and would participation.
recommended that we exclude otherwise be excluded from MIPS Response: We appreciate the support
individuals who do not meet the low- participation at the individual level, of the proposed policy to provide
volume threshold, even if the group would be required to participate in clinicians the ability to opt-in to the
practice otherwise met the low-volume MIPS at the group level if such eligible MIPS if they meet or exceed one, but not
threshold. clinicians are part of a group reporting all, of the low-volume threshold

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determinations, including as defined by accurately evaluate clinician Medicare beneficiaries. In addition, for
dollar amount, beneficiary count, or, if performance, which may result in performance periods occurring in 2018
established, items and services unequal outcomes based on clinician and future years, we are finalizing a
beginning with the 2019 MIPS participation at the individual- or modification to the low-volume
performance period. However, we are group-level and specialty types. The threshold determination period, in
not finalizing this proposal for the 2019 commenter recommended that we fully which the initial 12-month segment of
MIPS performance period. We are evaluate the effect of the opt-in policy the low-volume threshold determination
concerned that we will not be able to prior to implementing any changes. period would span from the last 4
operationalize this policy in a low- Response: We agree with the months of a calendar year 2 years prior
burden manner to MIPS eligible commenters concerns and acknowledge to the performance period followed by
clinicians as currently proposed. that allowing an opt-in option may the first 8 months of the next calendar
Specifically, our goal is to implement a present additional complexity and year and include a 30-day claims run
process whereby a clinician can be could inadvertantly create a model out; and the second 12-month segment
made aware of their low-volume where only high-performers opt-in. of the low-volume threshold
threshold status and make an informed Therefore, we are not finalizing this determination period would span from
decision on whether they will proposal for the 2019 MIPS performance the last 4 months of a calendar year, 1
participate in MIPS or not. We believe period. Rather, we are seeking further year prior to the performance period
it is critical to implement a process that comment on the best approach to followed by the first 8 months of the
provides the least burden to clinicians implementing the low-volume opt-in performance period in the next calendar
in communicating this decision to us. policy. This additional time will give us year and include a 30-day claims run
Therefore, in this final rule with the opportunity to perform additional out. In addition, in this final rule with
comment period, we are seeking analyses. We intend to revisit this comment period, we are seeking further
additional comments on the best policy in the 2018 notice-and-comment comment on the best approach to
approach of implementing a low- rulemaking cycle. implementing a low-volume threshold
volume threshold opt-in policy. As we Comment: Several commenters opt-in policy. We welcome suggestions
plan to revisit this policy in the 2018 supported the current low-volume on ways to implement the low-volume
notice-and-comment rulemaking cycle. threshold assessment period and threshold opt-in that does not add
This additional time and additional proposal to use a 30-day claims run out. additional burden to clinicians. We also
public comments will give us the One commenter agreed with retaining are interested in receiving feedback on
opportunity to explore how best to the low-volume threshold status if ways to mitigate our concern that only
implement this policy and to perform triggered during the first 12-month high-performers will choose to opt-in.
determination period regardless of the We also are soliciting comment on
additional analyses. We do not agree
status resulting from the second 12-
that we should allow any MIPS eligible whether our current application of the
month determination period. Another
clinicians that meet the low-volume low-volume threshold to groups is still
commenter did not support the use of a
threshold exclusion from any criterion appropriate. We refer readers to the CY
determination period for low-volume
to opt-in to MIPS, as it may impact our 2017 Quality Payment Program final
threshold that is outside of the
ability to create quality performance rule (81 FR 77062 through 77070) for a
performance period and believed that
benchmarks that meet our sample size discussion on how the low-volume
only data overlapping the performance
requirements. For example, if threshold is currently applied to groups.
period should be used to determine low-
particularly small practices or solo
volume threshold status. 3. Group Reporting
practitioners with low Part B beneficiary Response: We appreciate the
volumes opt-in, such clinicians may a. Background
commenters support of the low-volume
lack sufficient sample size to be scored threshold determination period and the As discussed in the CY 2017 Quality
on many quality measures, especially proposed use of a 30-day claims run out. Payment Program final rule, we
measures that do not apply to all of a We believe that it is beneficial for MIPS established the following requirements
MIPS eligible clinicians patients. In eligible clinicians to know whether they for groups (81 FR 77072):
addition, we do not believe MIPS are excluded under the low-volume
eligible clinicians who opt-in should Individual eligible clinicians and
threshold prior to the start of the individual MIPS eligible clinicians will
have different performance benchmarks performance period. In order to identify
nor avoid a negative payment have their performance assessed as a
these MIPS eligible clinicians prior to
adjustment. If the MIPS eligible group as part of a single TIN associated
the start of the performance period, we
clinician decides to opt-in, then they are with two or more eligible clinicians
must use historical data that is outside
committing to participating in the entire (including at least one MIPS eligible
of the performance period. We refer
program, which would include being clinician), as identified by an NPI, who
commenters to the CY 2017 Quality
assessed on the same criteria as other have reassigned their Medicare billing
Payment Program final rule (82 FR
MIPS eligible clinicians. rights to the TIN (at 414.1310(e)(1)).
77069 through 77070) for a full
Comment: A few commenters discussion of this policy. A group must meet the definition of
opposed the proposed policy to provide Final Action: After consideration of a group at all times during the
clinicians the ability to opt-in to the the public comments, we are finalizing performance period for the MIPS
MIPS if they meet or exceed one, but not our proposal to define at 414.1305 an payment year in order to have its
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all, of the low-volume threshold individual eligible clinician or group performance assessed as a group (at
determinations, including as defined by that does not exceed the low-volume 414.1310(e)(2)).
dollar amount, beneficiary count, or, if threshold as an individual eligible Individual eligible clinicians and
established, items and services clinician or group that, during the low- individual MIPS eligible clinicians
beginning with the 2019 MIPS volume threshold determination period, within a group must aggregate their
performance period. One commenter has Medicare Part B allowed charges performance data across the TIN to have
believed that an opt-in policy would less than or equal to $90,000 or provides their performance assessed as a group
complicate the programs ability to care for 200 or fewer Part B-enrolled (at 414.1310(e)(3)).

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A group that elects to have its Entities to report using the CMS Web We received several comments on
performance assessed as a group will be Interface are not required to register for subgroup level policies and will take
assessed as a group across all four MIPS the CMS Web Interface or administer them into consideration for future
performance categories (at the CAHPS for MIPS survey separately rulemaking.
414.1310(e)(4)). from the APM.
We stated in the CY 2017 Quality When groups submit data utilizing 4. Virtual Groups
Payment Program final rule that groups third party intermediaries, such as a a. Background
attest to their group size for purpose of qualified registry, QCDR, or EHR, we are There are generally three ways to
using the CMS Web Interface or able to obtain group information from participate in MIPS: (1) Individual-level
identifying as a small practice (81 FR the third party intermediary and discern reporting; (2) group-level reporting; and
77057). In section II.C.1.c. of this final whether the data submitted represents (3) virtual group-level reporting. In the
rule with comment period, we are group submission or individual CY 2018 Quality Payment Program
finalizing our proposal to modify the submission once the data are submitted. proposed rule (82 FR 30027 through
way in which we determine small In the CY 2017 Quality Payment
30034), we proposed to establish
practice size by establishing a process Program final rule (81 FR 77072 through
requirements for MIPS participation at
under which CMS would utilize claims 77073), we discussed the
implementation of a voluntary the virtual group level.
data to make small practice size
Section 1848(q)(5)(I) of the Act
determinations. In addition, in section registration process if technically
provides for the use of voluntary virtual
II.C.4.e. of this final rule comment feasible. Since the publication of the CY
2017 Quality Payment Program final groups for certain assessment purposes,
period, we are finalizing our proposal to
rule, we have determined that it is not including the election of certain
establish a policy under which CMS
technically feasible to develop and practices to be a virtual group and the
would utilize claims data to determine
build a voluntary registration process. requirements for the election process.
group size for groups of 10 or fewer
Until further notice, we are not Section 1848(q)(5)(I)(i) of the Act
eligible clinicians seeking to form or
implementing a voluntary registration provides that MIPS eligible clinicians
join a virtual group.
As noted in the CY 2017 Quality process. electing to be a virtual group must: (1)
Payment Program final rule, group size Also, in the CY 2017 Quality Payment Have their performance assessed for the
would be determined before exclusions Program final rule (81 FR 77075), we quality and cost performance categories
are applied (81 FR 77057). We note that expressed our commitment to pursue in a manner that applies the combined
group size determinations are based on the active engagement of stakeholders performance of all the MIPS eligible
the number of NPIs associated with a throughout the process of establishing clinicians in the virtual group to each
TIN, which would include individual and implementing virtual groups. Please MIPS eligible clinician in the virtual
eligible clinicians (NPIs) who may be refer to the CY 2018 Quality Payment group for the applicable performance
excluded from MIPS participation and Program proposed rule (82 FR 30027) period; and (2) be scored for the quality
do not meet the definition of a MIPS for a full discussion of the public and cost performance categories based
eligible clinician. comments and additional stakeholder on such assessment for the applicable
feedback we received in response to the performance period. Section
b. Registration CY 2017 Quality Payment Program final 1848(q)(5)(I)(ii) of the Act requires the
As discussed in the CY 2017 Quality rule and additional stakeholder Secretary to establish and implement, in
Payment Program final rule (81 FR feedback gathered through hosting accordance with section
77072 through 77073), we established several virtual group listening sessions 1848(q)(5)(I)(iii) of the Act, a process
the following policies: and convening user groups. that allows an individual MIPS eligible
A group must adhere to an election As discussed in the CY 2018 Quality clinician or a group consisting of not
process established and required by Payment Program proposed rule (82 FR more than 10 MIPS eligible clinicians to
CMS ( 414.1310(e)(5)), which includes: 30027), one of the overarching themes elect, for a performance period, to be a
++ Groups will not be required to we have heard is that we make an virtual group with at least one other
register to have their performance option available to groups that would such individual MIPS eligible clinician
assessed as a group except for groups allow a portion of a group to report as or group. Virtual groups may be based
submitting data on performance a separate subgroup on measures and on appropriate classifications of
measures via participation in the CMS activities that are more applicable to the providers, such as by geographic areas
Web Interface or groups electing to subgroup and be assessed and scored or by provider specialties defined by
report the CAHPS for MIPS survey for accordingly based on the performance of nationally recognized specialty boards
the quality performance category. For all the subgroup. In future rulemaking, we of certification or equivalent
other data submission mechanisms, intend to explore the feasibility of certification boards.
groups must work with appropriate establishing group-related policies that Section 1848(q)(5)(I)(iii) of the Act
third party intermediaries as necessary would permit participation in MIPS at provides that the virtual group election
to ensure the data submitted clearly a subgroup level and create such process must include the following
indicates that the data represent a group functionality through a new identifier. requirements: (1) An individual MIPS
submission rather than an individual Therefore, we solicited public comment eligible clinician or group electing to be
submission. on the ways in which participation in in a virtual group must make their
++ In order for groups to elect MIPS at the subgroup level could be election prior to the start of the
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participation via the CMS Web Interface established. In addition, in this final applicable performance period and
or administration of the CAHPS for rule with comment period, we are cannot change their election during the
MIPS survey, such groups must register seeking comment on additional ways to performance period; (2) an individual
by June 30 of the applicable define a group, not solely based on a MIPS eligible clinician or group may
performance period (that is, June 30, TIN. For example, redefining a group to elect to be in no more than one virtual
2018, for performance periods occurring allow for practice sites to be reflected group for a performance period, and, in
in 2018). We note that groups and/or for specialties within a TIN to the case of a group, the election applies
participating in APMs that require APM create groups. to all MIPS eligible clinicians in the

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group; (3) a virtual group is a billing under such TIN) or a group with with the physician self-referral law (82
combination of TINs; (4) requirements 10 or fewer eligible clinicians (as such FR 30028).
providing for formal written agreements terms are defined at 414.1305) under We refer readers to section II.C.4.b.(3)
among individual MIPS eligible the TIN that elects to form a virtual of this final rule with comment period
clinicians and groups electing to be a group with at least one other such solo for a summary of the public comments
virtual group; and (5) such other practitioner or group for a performance we received on these proposals and our
requirements as the Secretary period for a year (82 FR 30027 through responses.
determines appropriate. 30028). (2) Application to Groups Containing
b. Definition of a Virtual Group With regard to the low-volume Participants in a MIPS APM or an
threshold, we recognized that such Advanced APM
(1) Generally determinations are made at the
individual and group level, but not at Additionally, we recognized that
As noted above, section there are circumstances in which a TIN
1848(q)(5)(I)(ii) of the Act requires the the virtual group level (82 FR 30031).
For example, if an individual MIPS may have one portion of its NPIs
Secretary to establish and implement, in participating under the generally
accordance with section eligible clinician is part of a practice
applicable MIPS scoring criteria while
1848(q)(5)(I)(iii) of the Act, a process that is participating in MIPS (that is,
the remaining portion of NPIs under the
that allows an individual MIPS eligible reporting) at the individual level, then
TIN is participating in a MIPS APM or
clinician or group consisting of not the low-volume threshold determination
an Advanced APM under the MIPS
more than 10 MIPS eligible clinicians to is made at the individual level.
APM scoring standard (82 FR 30028). To
elect, for a performance period, to be a Whereas, if an individual MIPS eligible
clarify, for all groups, including those
virtual group with at least one other clinician is part of a practice that is
containing participants in a MIPS APM
such individual MIPS eligible clinician participating in MIPS (that is, reporting)
or an Advanced APM, the groups
or group. Given that section at the group level, then the low-volume
performance assessment will be based
1848(q)(5)(I)(iii)(III) of the Act provides threshold determination is made at the on the performance of the entire TIN.
that a virtual group is a combination of group level and would be applicable to Generally, for groups other than those
TINs, we interpreted the references to such MIPS eligible clinician regardless containing participants in a MIPS APM
an individual MIPS eligible clinician of the low-volume threshold or an Advanced APM, each MIPS
in section 1848(q)(5)(I)(ii) of the Act to determination made at the individual eligible clinician under the TIN (TIN/
mean a solo practitioner, which, for level. Similarly, if a solo practitioner or NPI) receives a MIPS adjustment based
purposes of section 1848(q)(5)(I) of the a group with 10 or fewer eligible on the entire groups performance
Act, we proposed to define as a MIPS clinicians seeks to participate in MIPS assessment (entire TIN). For groups
eligible clinician (as defined at (that is, report) at the virtual group containing participants in a MIPS APM
414.1305) who bills under a TIN with level, then the low-volume threshold or an Advanced APM, only the portion
no other NPIs billing under such TIN determination made at the individual or of the TIN that is being scored for MIPS
(82 FR 30027). group level, respectively, would be according to the generally applicable
Also, we recognized that a group applicable to such solo practitioner or scoring criteria (TIN/NPI) receives a
(TIN) may include not only NPIs who group. Thus, solo practitioners or MIPS adjustment based on the entire
meet the definition of a MIPS eligible groups with 10 or fewer eligible groups performance assessment (entire
clinician, but also NPIs who do not meet clinicians that are determined not to TIN). The remaining portion of the TIN
the definition of a MIPS eligible exceed the low-volume threshold at the that is being scored according to the
clinician at 414.1305 or who are individual or group level, respectively, APM scoring standard (TIN/NPI)
excluded from the definition of a MIPS would not be eligible to participate in receives a MIPS adjustment based on
eligible clinician under 414.1310(b) or MIPS as an individual, group, or virtual that standard. We noted that such
(c). Thus, we interpreted the references group, as applicable. participants may be excluded from
to a group consisting of not more than Given that a virtual group must be a MIPS if they achieve QP or Partial QP
10 MIPS eligible clinicians in section combination of TINs, we recognized that status. For more information, we refer
1848(q)(5)(I)(ii) of the Act to mean a the composition of a virtual group could readers to the CY 2017 Quality Payment
group with 10 or fewer eligible include, for example, one solo Program final rule (81 FR 77058, 77330
clinicians (as such terms are defined at practitioner (NPI) who is practicing through 77331).
414.1305) (82 FR 30027). Under under multiple TINs (TIN A and TIN B), We proposed to apply a similar policy
414.1310(d), the MIPS payment in which the solo practitioner would be to groups, including those containing
adjustment would apply only to NPIs in able to form a virtual group with his or participants in a MIPS APM or an
the virtual group who meet the her own self based on each TIN assigned Advanced APM, that are participating in
definition of a MIPS eligible clinician at to the solo practitioner (TIN A/NPI and MIPS as part of a virtual group (82 FR
414.1305 and who are not excluded TIN B/NPI) (82 FR 30032). As discussed 30028). Specifically, for groups other
from the definition of a MIPS eligible in section II.C.4.b.(3) of this final rule than those containing participants in a
clinician under 414.1310(b) or (c). We with comment period, we did not MIPS APM or an Advanced APM, each
noted that groups must include at least propose to establish a limit on the MIPS eligible clinician under the TIN
one MIPS eligible clinician in order to number of TINs that may form a virtual (TIN/NPI) would receive a MIPS
meet the definition of a group at group at this time. adjustment based on the virtual groups
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414.1305 and thus be eligible to form Lastly, we noted that qualification as combined performance assessment
or join a virtual group. a virtual group for purposes of MIPS (combination of TINs). For groups
We proposed to define a virtual group does not change the application of the containing participants in a MIPS APM
at 414.1305 as a combination of two or physician self-referral law to a financial or an Advanced APM, only the portion
more TINs composed of a solo relationship between a physician and an of the TIN that is being scored for MIPS
practitioner (that is, a MIPS eligible entity furnishing designated health according to the generally applicable
clinician (as defined at 414.1305) who services, nor does it change the need for scoring criteria (TIN/NPI) would receive
bills under a TIN with no other NPIs such a financial relationship to comply a MIPS adjustment based on the virtual

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groups combined performance We solicited public comment on these groups, or allow multiple TINs within a
assessment (combination of TINs). As proposals, as well as our approach of health care delivery system to report as
discussed in section II.C.6.g. of this final not establishing appropriate a virtual group.
rule with comment period, we proposed classifications (such as by geographic Response: In the CY 2017 Quality
to use waiver authority to ensure that area or by specialty) regarding virtual Payment Program final rule (81 FR
the remaining portion of the TIN that is group composition or a limit on the 77058), we noted that except for groups
being scored according to the APM number of TINs that may form a virtual containing APM participants, we do not
scoring standard (TIN/NPI) would group at this time. permit groups to split TINs if they
receive a MIPS adjustment based on that We noted that we received public choose to participate in MIPS as a
standard. We noted that such comments in response to the CY 2017 group. As we considered the option of
participants may be excluded from Quality Payment Program final rule and permitting groups to split TINs, we
MIPS if they achieve QP or Partial QP additional stakeholder feedback by identified several issues that would
status. hosting several virtual group listening make it challenging and cumbersome to
We refer readers to section II.C.4.b.(3) sessions and convening user groups (82 implement a split TIN option such as
of this final rule with comment period FR 30028). We refer readers to the CY the administrative burden of groups
for a summary of the public comments 2018 Quality Payment Program having to monitor and track which NPIs
we received on these proposals and our proposed rule (82 FR 30027) for a are reporting under which portion of a
responses. summary of these comments and our split TIN and the identification of
response. appropriate criteria to be used for
(3) Appropriate Classifications
The following is a summary of the determining the ways in which groups
As noted above, the statute provides public comments received regarding our would be able to split TINs (for
the Secretary with discretion to proposals, as well as our approach of example, based on specialty, practice
establish appropriate classifications not establishing appropriate site, location, health IT systems, or other
regarding the composition of virtual classifications (such as by geographic factors). However, we recognize that
groups, such as by geographic area or by area or by specialty) regarding virtual there are certain advantages for allowing
specialty. We recognized that virtual group composition or a limit on the TINs to split, such as those the
groups would each have unique number of TINs that may form a virtual identified by the commenter. We intend
characteristics and varying patient group at this time. to explore the option of permitting
populations. However, we believe it is Comment: A majority of commenters groups to split TINs, and any changes
important for virtual groups to have the supported the concept of virtual groups, would be proposed in future
flexibility to determine their own as defined, as a participation option rulemaking. Thus, we consider a group
composition at this time, and, as a available under MIPS. to mean an entire single TIN that elects
result, we did not propose to establish Response: We appreciate the support to participate in MIPS at the group or
any such classifications regarding from the commenters. virtual group level. However, for
virtual group composition (82 FR Comment: Several commenters did multiple TINs that are within a health
30028). not support virtual groups being limited care delivery system, such TINs would
We further noted that the statute does to groups consisting of not more than 10 be able to form a virtual group provided
not limit the number of TINs that may eligible clinicians and requested that that each TIN has 10 or fewer eligible
form a virtual group, and we did not CMS expand virtual group participation clinicians.
propose to establish such a limit at this to groups with more than 10 eligible Comment: A significant portion of
time (82 FR 30028). We did consider clinicians. commenters expressed concern
proposing to establish such a limit, such Response: As noted above, we regarding the ineligibility of virtual
as 50 or 100 participants. In particular, interpreted the references to a group group participation for solo
we were concerned that virtual groups consisting of not more than 10 MIPS practitioners and groups that do not
of too substantial a size (for example, 10 eligible clinicians in section exceed the low-volume threshold. The
percent of all MIPS eligible clinicians in 1848(q)(5)(I)(ii) of the Act to mean a commenters noted that such solo
a given specialty or sub-specialty) may group with 10 or fewer eligible practitioners and groups would not be
make it difficult to compare clinicians (as such terms are defined at able to benefit from participating as part
performance between and among 414.1305) (82 FR 30027). We do not of a virtual group and noted that the
clinicians. We believe that limiting the have discretion to expand virtual group purpose of virtual group formation was
number of virtual group participants participation to groups with more than to provide such solo practitioners and
could eventually assist virtual groups as 10 MIPS eligible clinicians. groups, which are otherwise unable to
they aggregate their performance data Comment: One commenter participate on their own, with an
across the virtual group. However, we recommended that CMS seek a technical opportunity to join with other such
believe that as we initially implement amendment to section 1848(q)(5)(I) of entities and collectively become eligible
virtual groups, it is important for virtual the Act to replace the group eligibility to participate in MIPS as part of a
groups to have the flexibility to threshold of 10 or fewer MIPS eligible virtual group. A few commenters
determine their own size, and thus, the clinicians with a patient population recommended that the low-volume
better approach is not to place such a requirement of at least 5,000 to improve threshold be conducted at the virtual
limit on virtual group size. We will the validity of the reporting of virtual group level.
monitor the ways in which solo groups. Response: In regard to stakeholder
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practitioners and groups with 10 or Response: We appreciate the feedback concerns pertaining to the low-volume
fewer eligible clinicians form virtual from the commenter and will take the threshold eligibility determinations
groups and may propose to establish commenters recommendation into made at the individual and group level
appropriate classifications regarding consideration. that would prevent certain solo
virtual group composition or a limit on Comment: A few commenters practitioners and groups from being
the number of TINs that may form a recommended that CMS allow a large, eligible to form a virtual group, we
virtual group in future rulemaking as multispecialty group under one TIN to believe there are statutory constraints
necessary. split into clinically relevant reporting that do not allow us to establish a low-

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volume threshold at the virtual group account variability in patient case-mix Act; and (4) a group that includes such
level. The statute includes specific and practice needs. clinicians. The definition of a MIPS
references to MIPS eligible clinicians Response: We appreciate the feedback eligible clinician includes a group and
throughout the virtual group provisions, from the commenter and will take the we define a group at 414.1305 to mean
and we believe that such references commenters recommendation into a single TIN with two or more eligible
were intended to limit virtual group consideration. clinicians (including at least one MIPS
participation to MIPS eligible Comment: One commenter indicated eligible clinician), as identified by their
clinicians, that is, eligible clinicians that the Quality Payment Program individual NPI, who have reassigned
who meet the definition of a MIPS encourages eligible clinicians to their billing rights to the TIN. Since a
eligible clinician and are not excluded aggregate data, share financial risk, and group is included under the definition
under the low-volume threshold or any work together as virtual groups, which of a MIPS eligible clinician, which
other statutory exclusion. As a result, promotes joint accountability and would include two or more eligible
we do not believe we are able to creates delivery systems that are better clinicians (including at least one MIPS
establish a low-volume threshold at the able to improve the cost, quality, and eligible clinician), our definition of a
virtual group level because a solo experience of care. As a result, the virtual group is consistent with statute.
practitioner or group would need to be commenter recommended that CMS
In regard to determining TIN size for
considered eligible to participate in issue detailed guidance and develop
purposes of virtual group eligibility, we
MIPS to form or join a virtual group. tools, resources, technical assistance,
count each NPI associated with a TIN in
Comment: Many commenters and other materials for guidance as to
order to determine whether or not a TIN
supported the flexibility provided for how clinicians can form virtual groups.
Response: We appreciate the feedback exceeds the threshold of 10 NPIs, which
virtual group composition, such as to is an approach that we believe provides
from the commenter and note that we
not have parameters pertaining to continuity over time if the definition of
intend to publish a virtual group toolkit
geographic area, specialty, size, or other a MIPS eligible clinician is expanded in
that provides information pertaining to
factors, while other commenters had future years under section
requirements and outlines the steps a
concerns that such flexibility could 1848(q)(1)(C)(i)(II) of the Act to include
virtual group would pursue during the
circumvent bona fide clinical reasons other eligible clinicians. We considered
election process, which can be accessed
for collaboration, incentivize practice on the CMS Web site at https:// an alternative approach for determining
consolidation, and cause an increase in www.cms.gov/Medicare/Quality- TIN size, which would determine TIN
costs without improving quality and Initiatives-Patient-Assessment- size for virtual group eligibility based on
health outcomes. Instruments/Value-Based-Programs/ NPIs who are MIPS eligible clinicians.
Response: We appreciate the support MACRA-MIPS-and-APMs/MACRA- However, as we conducted a
from the commenters regarding the MIPS-and-APMs.html. comparative assessment of the
flexibility we are providing to virtual Comment: A few commenters application of such alternative approach
groups pertaining to composition. In recommended that only MIPS eligible with the current definition of a MIPS
regard to concerns from other clinicians be considered as part of a eligible clinician (as defined at
commenters regarding such flexibility, virtual group as written in the statute. 414.1305) and a potential expanded
we note that TINs vary in size, clinician The commenters indicated that CMS definition of a MIPS eligible clinician,
composition, patient population, continues to include all eligible we found that such an approach could
resources, technological capabilities, clinicians versus only MIPS eligible create confusion as to which factors
geographic area, and other clinicians in the count to determine TIN determine virtual group eligibility and
characteristics, and may join or form size and requested that CMS instead cause the pool of virtual group eligible
virtual groups for various reasons, and rely on the not more than 10 MIPS TINs to significantly be reduced once
we do not want to inhibit virtual group eligible clinicians language in the the definition of a MIPS eligible
formation due to parameters. At this statute, which would allow more groups clinician would be expanded, which
juncture of virtual group to take advantage of the virtual group may impact a larger portion of virtual
implementation, we believe that virtual reporting option and focus more directly groups that intend to participate in
groups should have the flexibility to on the number of clinicians who are MIPS as a virtual group for consecutive
determine their composition and size, participating in and contributing to performance periods. Such impact
and thus we do not want to limit the MIPS rather than clinicians who are would be the result of the current
ways in which virtual groups are excluded. definition of a MIPS eligible clinician
composed. However, we encourage TINs Response: We note that our proposed being narrower than the potential
within virtual groups to assess means definition of a virtual group reflects the expanded definition of a MIPS eligible
for promoting and enhancing the statutory premise of virtual group clinician. For example, under the
coordination of care and improving the participation pertaining to MIPS eligible recommended approach, a TIN with a
quality of care and health outcomes. We clinicians. In the CY 2017 final rule (81 total of 15 NPIs (10 MIPS eligible
will monitor the ways in which solo FR 77539), we define a MIPS eligible clinicians and 5 eligible clinicians)
practitioners and groups with 10 or clinician (identified by a unique billing would not exceed the threshold of 10
fewer eligible clinicians form virtual TIN and NPI combination used to assess MIPS eligible clinicians and would be
groups and may propose to establish performance) at 414.1305 to mean any eligible to participate in MIPS as a
appropriate classifications regarding of the following (excluding those virtual group for the 2018 performance
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virtual group composition or a limit on identified at 414.1310(b)): (1) A period; however, if the definition of a
the number of TINs that may form a physician as defined in section 1861(r) MIPS eligible clinician were expanded
virtual group in future rulemaking as of the Act; (2) a physician assistant, a through rulemaking for the 2019
necessary. nurse practitioner, and clinical nurse performance period, such TIN, with no
Comment: One commenter requested specialist as such terms are defined in change in TIN size (15 NPIs), would
that CMS continue to examine the section 1861(aa)(5) of the Act; (3) a exceed the threshold of 10 MIPS eligible
formation and implementation of virtual certified registered nurse anesthetist as clinicians if 1 or more of the 5 eligible
groups, ensuring equity and taking into defined in section 1861(bb)(2) of the clinicians met the expanded definition

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of a MIPS eligible clinician and no At this juncture, we are not TIN for purposes of participation in
longer eligible to participate in MIPS as establishing additional classifications MIPS, nor does any eligible clinician in
part of a virtual group. We did not (such as by geographic area or by the virtual group need to reassign their
pursue such an approach given that it specialty) regarding virtual group billing rights to a new or different TIN.
did not align with our objective of composition or a limit on the number of Comment: A few commenters
establishing virtual group eligibility TINs that may form a virtual group. indicated that EHR developers need to
policies that are simplistic in know the specifications for the virtual
c. Virtual Group Identifier for group identifier as soon as technically
understanding and provide continuity. Performance
Final Action: After consideration of feasible in order for such specifications
the public comments received, we are To ensure that we have accurately to be included in their development
finalizing with modification our captured all of the MIPS eligible efforts and implemented early in 2018.
proposal to define a solo practitioner at clinicians participating in a virtual One commenter indicated that qualified
414.1305 as a practice consisting of group, we proposed that each MIPS registries submit data at the TIN level
one eligible clinician (who is also a eligible clinician who is part of a virtual for group reporting and that individual
MIPS eligible clinician). We are also group would be identified by a unique NPI data is effectively obscured, and
finalizing with modification our virtual group participant identifier (82 requested clarification regarding the
proposal to define a virtual group at FR 30028 through 30029). The unique type of information qualified registries
414.1305 as a combination of two or virtual group participant identifier would report for virtual groups, such as
more TINs assigned to one or more solo would be a combination of three the virtual group identifier alone (VG
practitioners or one or more groups identifiers: (1) Virtual group identifier XXXXXX) or the combination of all
consisting of 10 or fewer eligible (established by CMS; for example, three identifiers (VGXXXXXX, TIN
clinicians, or both, that elect to form a XXXXXX); (2) TIN (9 numeric XXXXXXXXX, NPI11111111111).
characters; for example, XXXXXXXXX); Response: For a virtual groups that are
virtual group for a performance period
and (3) NPI (10 numeric characters; for determined to have met the virtual
for a year. We are modifying the
example, 1111111111). For example, a group formation criteria and approved
definition (i) to remove the redundant
virtual participant identifier could be to participate in MIPS as an identified
phrases with at least one other such
VGXXXXXX, TINXXXXXXXXX, NPI official virtual group, we will notify
solo practitioner or group and
11111111111. We solicited public official designated virtual group
unnecessary parenthetical cross
comment on this proposal. representatives of their official virtual
references; (ii) to accurately characterize
The following is a summary of the group status and issue a virtual group
TINs as being assigned to (rather than identifier. We intend to notify virtual
composed of) a solo practitioner or public comments received regarding our
proposal. groups of their official status as close to
group; and (iii) to clearly indicate that the start of the performance period as
Comment: A majority of commenters
a virtual group can be composed of one technically feasible. Virtual groups will
expressed support for our proposal.
or more solo practitioners or groups of Response: We appreciate the support need to provide their virtual group
10 or fewer eligible clinicians. We note from the commenters. identifiers to the third party
that we are modifying our proposed Comment: One commenter indicated intermediaries that will be submitting
definitions for greater clarity and that a virtual group identifier would their performance data, such as
consistency with established MIPS lead to administrative simplification qualified registries, QCDRs, and/or
terminology. and more accurate identification of EHRs. Qualified registries, QCDRs, and
We are also finalizing our proposal MIPS eligible clinicians caring for EHRs will include the virtual group
that for groups (TINs) that participate in Medicare beneficiaries, which could be identifier alone (VGXXXXXX) in the
MIPS as part of a virtual group and do used in recognizing and eliminating file submissions. For virtual groups that
not contain participants in a MIPS APM redundancies in the payer system. elect to participate in MIPS via the CMS
or an Advanced APM, each MIPS Response: We appreciate the support Web Interface or administer the CAHPS
eligible clinician under the TIN (each from the commenter. We believe that for MIPS survey, they will register via
TIN/NPI) will receive a MIPS payment our proposed virtual group identifier the CMS Web Interface and include the
adjustment based on the virtual groups will accurately identify each MIPS virtual group identifier alone (VG
combined performance assessment eligible clinician participating in a XXXXXX) during registration. We
(combination of TINs). For groups virtual group and be easily implemented intend to update submission
(TINs) that participate in MIPS as part by virtual groups. specifications prior to the start of the
of a virtual group and contain Comment: One commenter thanked applicable submission period.
participants in a MIPS APM or an CMS for not requiring virtual groups to Comment: One commenter expressed
Advanced APM, only the portion of the form new TINs, which would add to the concerns regarding the burden of using
TIN that is being scored for MIPS administrative burden for entities a virtual group identifier and the added
according to the generally applicable electing to become virtual groups, while administrative complexity to the claims
scoring criteria will receive a MIPS another commenter requested process of using layered identifiers and
adjustment based on the virtual groups clarification regarding whether or not modifiers. The commenter requested
combined performance assessment members of a virtual group would need that CMS simplify the reporting process
(combination of TINs). As discussed in to submit a Reassignment of Benefits for MIPS eligible clinicians, groups, and
section II.C.6.g. of this final rule with Form (CMS855R) to the MAC and virtual groups rather than increase the
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comment period, the remaining portion reassign their billing rights to the administrative burden.
of the TIN that is being scored according elected virtual group. Response: We appreciate the feedback
to the APM scoring standard will Response: We note that a virtual from the commenter. We do not believe
receive a MIPS payment adjustment group is recognized as an official that the virtual group identifier would
based on that standard. We note that collective entity for reporting purposes, be burdensome for virtual groups to
such participants may be excluded from but is not a distinct legal entity for implement. We believe that our
MIPS if they achieve QP or Partial QP billing purposes. As a result, a virtual proposed virtual group identifier is the
status. group does not need to establish a new most appropriate and simple approach,

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which will allow for the accurate (2) Application of Non-Patient Facing practices by utilizing claims data; for
identification of each MIPS eligible Status to Virtual Groups performance periods occurring in 2018,
clinician participating in a virtual group With regard to the applicability of the we would identify small practices based
and be easily implemented by virtual non-patient facing MIPS eligible on 12 months of data starting from
groups. clinician-related policies to virtual September 1, 2016 to August 31, 2017
Final Action: After consideration of groups, in the CY 2017 Quality Payment (82 FR 30019 through 30020). We refer
the public comments received, we are Program final rule (81 FR 77048 through readers to section II.C.1.c. of this final
finalizing our proposal that each MIPS 77049), we defined the term non-patient rule with comment period for the
eligible clinician who is part of a virtual facing MIPS eligible clinician at discussion of our proposal to identify
group will be identified by a unique small practices by utilizing claims data.
414.1305 as an individual MIPS
virtual group participant identifier, We refer readers to section II.C.4.d.(3) of
eligible clinician that bills 100 or fewer
which will be a combination of three this final rule with comment period for
patient facing encounters (including
identifiers: (1) Virtual group identifier the discussion regarding how small
Medicare telehealth services defined in
(established by CMS; for example, practice status would apply to virtual
section 1834(m) of the Act) during the
groups for scoring under MIPS.
XXXXXX); (2) TIN (9 numeric non-patient facing determination We refer readers to section II.C.4.d.(5)
characters; for example, XXXXXXXXX); period, and a group provided that more of this final rule with comment period
and (3) NPI (10 numeric characters; for than 75 percent of the NPIs billing for a summary of the public comments
example, 1111111111). For example, a under the groups TIN meet the we received on our proposal to apply
virtual group participant identifier definition of a non-patient facing small practice status to virtual groups
could be VGXXXXXX, TIN individual MIPS eligible clinician and our responses.
XXXXXXXXX, NPI11111111111. during the non-patient facing
determination period. In the CY 2018 (4) Application of Rural Area and HSPA
d. Application of Group-Related Policies Practice Status to Virtual Groups
to Virtual Groups Quality Payment Program proposed rule
(82 FR 30021, 30029), we proposed to In the CY 2018 Quality Payment
(1) Generally modify the definition of a non-patient Program proposed rule (82 FR 30020
facing MIPS eligible clinician to include through 30021), we proposed to
In the CY 2017 Quality Payment
clinicians in a virtual group, provided determine rural area and HPSA practice
Program final rule (81 FR 77070 through
that more than 75 percent of the NPIs designations at the individual, group,
77072), we finalized various
billing under the virtual groups TINs and virtual group level. Specifically, for
requirements for groups under MIPS at
meet the definition of a non-patient performance periods occurring in 2018
414.1310(e), under which groups
facing individual MIPS eligible clinician and future years, we proposed that an
electing to report at the group level are
during the non-patient facing individual MIPS eligible clinician, a
assessed and scored across the TIN for
determination period. We noted that group, or a virtual group with multiple
all four performance categories. In the
other policies previously established practices under its TIN or TINs within
CY 2018 Quality Payment Program
and proposed in the proposed rule for a virtual group would be designated as
proposed rule (82 FR 30029), we
non-patient facing groups would apply a rural area or HPSA practice if more
proposed to apply our previously
to virtual groups (82 FR 30029). For than 75 percent of NPIs billing under
finalized and proposed group-related
example, as discussed in section the individual MIPS eligible clinician or
policies to virtual groups, unless
II.C.1.e. of this final rule with comment groups TIN or within a virtual group, as
otherwise specified. We recognized that
period, virtual groups determined to be applicable, are designated in a ZIP code
there are instances in which we may
non-patient facing would have their as a rural area or HPSA. We noted that
need to clarify or modify the application
advancing care information performance other policies previously established
of certain previously finalized or
category automatically reweighted to and proposed in the proposed rule for
proposed group-related policies to
zero. rural area and HPSA groups would
virtual groups, such as the definition of We refer readers to section II.C.4.d.(5)
a non-patient facing MIPS eligible apply to virtual groups (82 FR 30029).
of this final rule with comment period We note that in section II.C.7.b.(1)(b) of
clinician; small practice, rural area and for a summary of the public comments
HPSA designations; and groups that this final rule with comment period, we
we received on these proposals and our describe our scoring proposals for
contain participants in a MIPS APM or responses.
an Advanced APM (see section II.C.4.b. practices that are in a rural area.
(3) Application of Small Practice Status We refer readers to section II.C.4.d.(5)
of this final rule with comment period).
to Virtual Groups of this final rule with comment period
More generally, such policies may
for a summary of the public comments
include, but are not limited to, those With regard to the application of we received on these proposals and our
that require a calculation of the number small practice status to virtual groups, responses.
of NPIs across a TIN (given that a virtual in the CY 2017 Quality Payment
group is a combination of TINs), the Program final rule (81 FR 77188), we (5) Applicability and Availability of
application of any virtual group defined the term small practices at Measures and Activities to Virtual
participants status or designation to the 414.1305 as practices consisting of 15 Groups
entire virtual group, and the or fewer clinicians and solo As noted above, we proposed to apply
applicability and availability of certain practitioners. In the CY 2018 Quality our previously finalized and proposed
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measures and activities to any virtual Payment Program proposed rule (82 FR group-related policies to virtual groups,
group participant and to the entire 30019, 30029), we proposed that a unless otherwise specified (82 FR
virtual group. virtual group would be identified as a 30029). In particular, we recognized that
We refer readers to section II.C.4.d.(5) small practice if the virtual group does the measures and activities applicable
of this final rule with comment period not have 16 or more eligible clinicians. and available to groups would also be
for a summary of the public comments In addition, we proposed for applicable and available to virtual
we received on these proposals and our performance periods occurring in 2018 groups. Virtual groups would be
responses. and future years to identify small required to meet the reporting

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requirements for each measure and virtual group would otherwise qualify TINs are in a ZIP code designated as a
activity, and the virtual group would be as a small practice and should not lose rural area or HPSA would be designated
responsible for ensuring that their the accommodations to which they as a rural area or HPSA practice at the
measure and activity data are aggregated would otherwise be entitled. The virtual group level. The commenters
across the virtual group (for example, commenters suggested that any virtual requested that CMS reduce the
across their TINs). We noted that other group, regardless of size, be considered threshold pertaining to rural area and
previously finalized and proposed a small practice. The commenters HPSA practice status for virtual groups
group-related policies pertaining to the further stated that small practices that and recommended that a virtual group
four performance categories would just slightly exceed the low-volume with more than 50 percent of the NPIs
apply to virtual groups. threshold may have the most challenges billing under a virtual groups TINs are
The following is a summary of the and difficulty succeeding in the Quality in a ZIP code designated as a rural area
public comments received regarding our Payment Program. or HPSA would be designated as a rural
proposals. Response: We note that virtual groups area or HPSA practice at the virtual
Comment: Many commenters with 15 or fewer eligible clinicians will group level.
supported our proposal to generally continue to be considered a small Response: We disagree with the
apply MIPS group-related policies to practice as a collective entity. The small recommendation from the commenters.
virtual groups, unless otherwise practice status is applied based on the In order for a virtual group to be
specified. The commenters indicated collective entity as a whole and not designated as a rural area or HPSA
that such alignment would ease undue based on the small practice status of practice, we believe that a significant
administrative and reporting burden. each TIN within a virtual group. If a portion of a virtual groups NPIs would
Response: We appreciate the support virtual group has 16 or more eligible need to be in a ZIP code designated as
from the commenters. clinicians, it would not be considered to a rural area or HPSA. Our proposal
Comment: Several commenters have a small practice status as a provides a balance between requiring
supported our proposal to modify the collective whole. We believe that our more than half of a virtual groups NPIs
definition of a non-patient facing MIPS approach is consistent with statute and to have such designations and requiring
eligible clinician to include clinicians in not unfair to small practices that are a all NPIs within a virtual group to have
a virtual group provided that more than part of virtual groups with 16 or more such designations. Also, our proposed
75 percent of the NPIs billing under the eligible clinicians. Section threshold pertaining to rural area and
virtual groups TINs meet the definition 1848(q)(2)(B)(iii) of the Act specifically HPSA practice status for virtual groups
of a non-patient facing individual MIPS refers to small practices of 15 or fewer aligns with other group-related and
eligible clinician. clinicians, and we do not believe it is virtual group policies, which creates
Response: We appreciate the support appropriate to apply such designation to continuity among policies and makes
from the commenters. a virtual group as a collective single virtual group implementation easier for
Comment: One commenter expressed entity when a virtual group has 16 or TINs forming virtual groups.
support for our proposal that a virtual more eligible clinicians. We encourage Comment: One commenter urged
group would be identified as a small small practices to weigh the benefit of CMS to eliminate the all-cause hospital
practice if the virtual group does not the special provisions specific to small readmission measure from the quality
have 16 or more eligible clinicians, practices against the benefits of virtual performance category score for virtual
while another commenter expressed group participation when considering groups with 16 or more eligible
support for our proposal that a virtual whether to form a virtual group that has clinicians. The commenter noted that
group with more than 75 percent of the 16 or more eligible clinicians. We refer virtual groups would be newly formed
NPIs billing under the virtual groups readers to section II.C.7.b.(1)(c) of this and unlikely to have the same
TINs are in a ZIP code designated as a final rule with comment for the infrastructure and care coordination
rural area or HPSA would be designated discussion regarding the scoring of functionality that established groups
as a rural area or HPSA practice at the small practices. We want to ensure that under a single TIN may have in place,
virtual group level. small practices have the ability to and that factoring the all-cause hospital
Response: We appreciate the support determine the most appropriate means readmission measure into their score
from the commenters regarding our for participating in MIPS, whether it be would be inappropriate.
proposals. as individuals, as a group or part of a Response: We recognize that small
Comment: Several commenters did virtual group. The formation of virtual practices, including solo practitioners,
not support our proposal that a virtual groups provides for a comprehensive would not be assessed on the all-cause
group would be identified as a small measurement of performance, shared hospital readmission measure as
practice if the virtual group does not responsibility, and an opportunity to individual TINs. However, we believe
have 16 or more eligible clinicians. The effectively and efficiently coordinate that the all-cause hospital readmission
commenters expressed concerns that the resources to achieve requirements under measure is an appropriate measure,
benefits of forming a virtual group could each performance category. A small when applicable, to assess performance
be outweighed by the loss of the practice may elect to join a virtual group under the quality performance category
proposed small practice bonus points in order to potentially increase their of virtual groups with 16 or more
for virtual groups with more than 15 performance under MIPS or elect to eligible clinicians that meet the case
eligible clinicians, and that the participate in MIPS as a group and take volume of 200 cases. For virtual groups
elimination of small practice bonus advantage of other flexibilities and that do not meet the minimum case
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points for such virtual groups would benefits afforded to small practices. We volume of 200, the all-cause hospital
undermine the establishment of small note that if a virtual group has 16 or readmission measure would not be
practice policies afforded to such more eligible clinicians, it will not be scored. Also, we believe that our
entities in statute. The commenters considered a small practice. approach for assessing performance
indicated that the formation of virtual Comment: A few commenters did not based on the all-cause hospital
groups would involve substantial support our proposal that a virtual readmission measure for virtual groups
administrative burdens for small group with more than 75 percent of the with 16 or more eligible clinicians is
practices, and that each TIN within a NPIs billing under the virtual groups appropriate because it reflects the same

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policy for groups, which was developed TINs within a virtual group would be aggregating data on the advancing care
as a requirement to reduce burden (such required to have certified EHR information performance category
measure is based on administrative technology. measures, particularly when TINs
claims data and does not require a Response: In general and unless stated within a virtual group may be using
separate submission of data) and ensure otherwise, for purposes of the advancing multiple CEHRT systems. For the 2018
that we do not unfairly penalize MIPS care information performance category, performance period, TINs within virtual
eligible clinicians or groups that did not the policies pertaining to groups will groups may be using systems which are
have adequate time to prepare apply to virtual groups. We refer readers certified to different CEHRT Editions.
adequately to succeed in the program to section II.C.6.f. of this final rule with We consider unique patients to be
while still rewarding high performers. comment period for more information individual patients treated by a TIN
Comment: One commenter supported on the generally applicable policies for within a virtual group who would
our proposal to generally apply our the advancing care information typically be counted as one patient in
group-related policies to virtual groups, performance category. the denominator of an advancing care
specifically with regard to the We note that as with virtual group information performance category
improvement activities performance reporting for the other MIPS measure. This patient may see multiple
category requirements, under which performance categories, to report as a MIPS eligible clinicians within a TIN
groups and virtual groups would receive virtual group, the virtual group will that is part of a virtual group, or may see
credit for an improvement activity as need to aggregate data for all of the MIPS eligible clinicians at multiple
long as one NPI under the groups TIN individual MIPS eligible clinicians practice sites of a TIN that is part of a
or virtual groups TINs performs an within the virtual group for which its virtual group. When aggregating
improvement activity for a continuous TINs have data in CEHRT. For solo performance on advancing care
90-day period. practitioners and groups that choose to information measures for virtual group
Response: We appreciate the support report as a virtual group, performance level reporting, we do not require that
from the commenter. on the advancing care information a virtual group determines that a patient
Comment: One commenter requested performance category objectives and seen by one MIPS eligible clinician (or
clarification regarding how the measures will be reported and evaluated at one location in the case of TINs
proposed group-related policy that at at the virtual group level. The virtual working with multiple CEHRT systems)
least 50 percent of the practice sites group will submit the data that its TINs is not also seen by another MIPS eligible
within a TIN must be certified or have utilizing CEHRT and exclude data clinician in the TIN that is part of the
recognized as a patient-centered not collected from a non-certified EHR virtual group or captured in a different
medical home or comparable specialty system. While we do not expect that CEHRT system. Virtual groups are
practice in order to receive full credit in every MIPS eligible clinician in a virtual provided with some flexibility as to the
the improvement activities performance group will have access to CEHRT, or method for counting unique patients in
category applies to virtual groups. that every measure will apply to every the denominators to accommodate such
Another commenter recommended that clinician in the virtual group, only those scenarios where aggregation may be
a virtual group receive full credit for the data contained in CEHRT should be hindered by systems capabilities across
improvement activities performance reported for the advancing care multiple CEHRT platforms. We refer
category if at least 50 percent of its information performance category. readers to section II.C.6.f.(4) of this final
eligible clinicians are certified or For example, the virtual group rule with comment for the discussion
recognized as a patient-centered calculation of the numerators and regarding certification requirements.
medical home or comparable specialty denominators for each measure must Comment: One commenter requested
practice. reflect all of the data from the that CMS require that a majority of
Response: As discussed in section individual MIPS eligible clinicians eligible clinicians within a virtual group
II.C.7.a.(5)(c) of this final rule with (unless a clinician can be excluded) that participate in activities to which the
comment period, in order for a group to have been captured in CEHRT for the virtual group attests in the improvement
receive full credit as a certified or given advancing care information activities and advancing care
recognized patient-centered medical performance category measure. If the information performance categories in
home or comparable specialty practice groups (not including solo practitioners) order for the virtual group to receive
under the improvement activities that are part of a virtual group have credit for those activities.
performance category, at least 50 CEHRT that is capable of supporting Response: We note that a virtual
percent of the practice sites within the group level reporting, the virtual group group would need to meet the group-
TIN must be recognized as a patient- would submit the aggregated data across related requirements under each
centered medical home or comparable the TINs produced by the CEHRT. If a performance category. For the
specialty practice. In order for a virtual group (TIN) that is part of a virtual improvement activities performance
group to receive full credit as a certified group does not have CEHRT that is category, a virtual group would meet the
or recognized patient-centered medical capable of supporting group level reporting requirements if at least one
home or comparable specialty practice reporting, such group would aggregate NPI within the virtual group completed
under the improvement activities the data by adding together the an improvement activity for a minimum
performance category, at least 50 numerators and denominators for each of a continuous 90-day period within
percent of the practice sites within the MIPS eligible clinician within the group CY 2018. In regard to the advancing care
TINs that are part of a virtual group for whom the group has data captured information performance category, a
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must be certified or recognized as a in CEHRT. If an individual MIPS virtual group would need to fulfill the
patient-centered medical home or eligible clinician meets the criteria to required base score measures for a
comparable specialty practice. exclude a measure, their data can be minimum of 90 days in order to earn
Comment: One commenter requested excluded from the calculation of that points for the advancing care
that CMS clarify how a virtual group particular measure only. information performance category.
would be expected to meet the We recognize that it can be difficult Additionally, virtual groups are able to
advancing care information performance to identify unique patients across a submit performance score measures and
category requirements and whether all virtual group for the purposes of bonus score measures in order to

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increase the number of points earned adjustment factor(s) for a performance must make their election prior to the
under the advancing care information period. In regard to an audit process, start of the applicable performance
performance category. virtual groups would be subject to the period and cannot change their election
Comment: A few commenters MIPS data validation and auditing during the performance period; and (2)
requested that virtual groups have the requirements as described in section an individual MIPS eligible clinician or
same flexibility afforded to groups II.C.9.c. of this final rule with comment group may elect to be in no more than
regarding the ability to report on period. one virtual group for a performance
different measures and utilize multiple Final Action: After consideration of period, and, in the case of a group, the
submission mechanisms under each public comments received, we are election applies to all MIPS eligible
performance category. finalizing our proposal to apply our clinicians in the group. Accordingly, we
Response: We note that virtual groups previously finalized and proposed proposed to codify at 414.1315(a) that
will have the same flexibility as groups group-related policies to virtual groups, a solo practitioner (as defined at
to report on measures and activities that unless otherwise specified. 414.1305) or group consisting of 10 or
are applicable and available to them. As We are also finalizing our proposal to fewer eligible clinicians (as such terms
discussed in section II.C.6.a.(1) of this modify the definition of a non-patient are defined at 414.1305) electing to be
final rule with comment period, the facing MIPS eligible clinician at in a virtual group must make their
submission mechanisms available to 414.1305 to include a virtual group, election prior to the start of the
groups under each performance category provided that more than 75 percent of applicable performance period and
will also be available to virtual groups. the NPIs billing under the virtual cannot change their election during the
Similarly, virtual groups will also have groups TINs meet the definition of a performance period (82 FR 30029
the same option as groups to utilize non-patient facing individual MIPS through 30030). Virtual group
multiple submission mechanisms, but eligible clinician during the non-patient participants may elect to be in no more
only one submission mechanism per facing determination period. Other than one virtual group for a performance
performance category for the 2018 previously finalized and proposed period, and, in the case of a group, the
performance period. However, starting policies related to non-patient facing election applies to all MIPS eligible
with the 2019 performance period, MIPS eligible clinicians would apply to clinicians in the group.
groups and virtual groups will be able such virtual groups. We noted that in the case of a TIN
to utilize multiple submission We are also finalizing our proposal within a virtual group being acquired or
mechanisms for each performance that a virtual group will be considered merged with another TIN, or no longer
category. a small practice if a virtual group
Comment: A few commenters operating as a TIN (for example, a group
consists of 15 or fewer eligible practice closes), during a performance
recommended that CMS establish
clinicians. Other previously finalized period, such solo practitioners or
performance feedback for virtual groups
and proposed policies related to small groups performance data would
and each TIN within a virtual group that
practices would apply to such virtual continue to be attributed to the virtual
includes complete performance data for
groups. group (82 FR 30032). The remaining
each performance category. One
We are also finalizing our proposal parties to the virtual group would
commenter requested that CMS provide
that a virtual group will be designated continue to be part of the virtual group
instructions regarding the appeal and
as a rural area or HPSA practice if more even if only one solo practitioner or
audit process for virtual groups and
than 75 percent of NPIs billing under group remains. We consider a TIN that
TINs within a virtual group.
Response: We note that performance the virtual groups TINs are designated is acquired or merged with another TIN,
feedback for virtual groups will be in a ZIP code as a rural area or HPSA, or no longer operating as a TIN (for
similar to feedback reports for groups, the virtual groups TINs are designated example, a group practice closes), to
which is based on the performance of as rural areas or HPSA practices. Other mean a TIN that no longer exists or
the entire group for each performance previously finalized and proposed operates under the auspices of such TIN
category. We note that virtual groups are policies related to rural area or HPSA during a performance period.
required to aggregate their data across practices would apply to such virtual In order to provide support and
the virtual group, and will be assessed groups. reduce burden, we intend to make
and scored at the virtual group level. In response to public comments, we technical assistance (TA) available, to
Each TIN within the virtual group will are also finalizing that a virtual group the extent feasible and appropriate, to
receive feedback on their performance will be considered a certified or support clinicians who choose to come
based on participation in MIPS as a recognized patient-centered medical together as a virtual group. Clinicians
virtual group, in which each TIN under home or comparable specialty practice can access the TA infrastructure and
the virtual group will have the same under 414.1380(b)(3)(iv) if at least 50 resources that they may already be
performance feedback applicable to the percent of the practices sites within the utilizing. For Quality Payment Program
four performance categories. At this TINs are certified or recognized as a year 3, we intend to provide an
juncture, it is not technically feasible patient-centered medical home or electronic election process if technically
nor do we believe it is appropriate for comparable specialty practice. feasible. We proposed that clinicians
us to de-aggregate data at the virtual e. Virtual Group Election Process who do not elect to contact their
group level and reassess performance designated TA representative would
(1) Generally still have the option of contacting the
data at the TIN or TIN/NPI level without
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requiring TINs and/or TIN/NPIs to As noted in section II.C.4.a. of this Quality Payment Program Service
submit data separately. We refer readers final rule with comment period, section Center to obtain information pertaining
to section II.C.9.a. of this final rule with 1848(q)(5)(I)(iii)(I) and (II) of the Act to virtual groups (82 FR 30030).
comment period for the discussion provides that the virtual group election We refer readers to section II.C.4.e.(3)
pertaining to performance feedback. process must include certain of this final rule with comment period
Moreover, we note that virtual groups requirements, including that: (1) An for a summary of the public comments
will have an opportunity to request a individual MIPS eligible clinician or we received on these proposals and our
targeted review of their MIPS payment group electing to be in a virtual group responses.

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(2) Virtual Group Election Deadline virtual group implementation, and other otherwise, the TINs status would be
For performance periods occurring in related activities; whereas, by engaging determined at the time that the TINs
2018 future years, we proposed to directly in stage 2 as an initial step, solo virtual group election is submitted. For
establish a virtual group election period practitioners and groups might conduct example, if a group contacted their
(82 FR 30030). Specifically, we all such efforts to only have their designated TA representative on
proposed to codify at 414.1315(a) that election registration be rejected with no October 20, 2017, the claims data
a solo practitioner (as defined at recourse or remaining time to amend analysis would include the months of
414.1305) or group consisting of 10 or and resubmit. July through September of 2017, and, if
In stage 1, solo practitioners and determined not to exceed 10 eligible
fewer eligible clinicians (as such terms
groups with 10 or fewer eligible clinicians, the TINs size would be
are defined at 414.1305) electing to be
clinicians interested in forming or determined at such time, and the TINs
in a virtual group must make their
joining a virtual group would have the eligibility status would be retained for
election by December 1 of the calendar option to contact their designated TA
year preceding the applicable the duration of the election period and
representative in order to obtain the CY 2018 performance period. If
performance period. A virtual group information pertaining to virtual groups
representative would be required to another group contacted their
and/or determine whether or not they designated TA representative on
make the election, on behalf of the are eligible, as it relates to the practice
members of a virtual group, regarding November 20, 2017, the claims data
size requirement of a solo practitioner or analysis would include the months of
the formation of a virtual group for the a group of 10 or fewer eligible
applicable performance period, by the July through October of 2017, and, if
clinicians, to participate in MIPS as a determined not to exceed 10 eligible
election deadline. For example, a virtual virtual group ( 414.1315(c)(1)(i)).
group representative would need to clinicians, the TINs size would be
During stage 1 of the virtual group determined at such time, and the TINs
make an election, on behalf of the election process, we would determine
members of a virtual group, by eligibility status would be retained for
whether or not a TIN is eligible to form the duration of the election period and
December 1, 2017 for the members of or join a virtual group. In order for a
the virtual group to participate in MIPS the CY 2018 performance period.
solo practitioner to be eligible to form or We believe such a virtual group
as a virtual group during the CY 2018 join a virtual group, the solo practitioner
performance period. We intend to determination period process provides a
would need to meet the definition of a relative representation of real-time TIN
publish the beginning date of the virtual solo practitioner at 414.1305 and not
group election period applicable to size for purposes of virtual group
be excluded from MIPS under
performance periods occurring in 2018 eligibility and allows solo practitioners
414.1310(b) or (c). In order for a group
and future years in subregulatory and groups to know their real-time
to be eligible to form or join a virtual
guidance. eligibility status immediately and plan
group, a group would need to meet the
We refer readers to section II.C.4.e.(3) accordingly for virtual group
definition of a group at 414.1305, have
of this final rule with comment period implementation. It is anticipated that
a TIN size that does not exceed 10
for a summary of the public comments starting in September of each calendar
eligible clinicians, and not be excluded
we received on these proposals and our year prior to the applicable performance
from MIPS under 414.1310(b) or (c).
responses. period, solo practitioners and groups
For purposes of determining TIN size
would be able to contact their
(3) Virtual Group Eligibility for virtual group participation
eligibility, we coined the term virtual designated TA representative and
Determinations and Formation inquire about virtual group participation
group eligibility determination period
We proposed to codify at and defined it to mean an analysis of eligibility. We noted that TIN size
414.1315(c) a two-stage virtual group claims data during an assessment period determinations are based on the number
election process, stage 1 of which is of up to 5 months that would begin on of NPIs associated with a TIN, which
optional, for performance periods July 1 and end as late as November 30 would include clinicians (NPIs) who do
occurring in 2018 and 2019 (82 FR of the calendar year prior to the not meet the definition of a MIPS
30030 through 30032). Stage 1 pertains applicable performance period and eligible clinician at 414.1305 or who
to virtual group eligibility includes a 30-day claims run out. are excluded from MIPS under
determinations, and stage 2 pertains to To capture a real-time representation 414.1310(b) or (c).
virtual group formation. We noted that of TIN size, we proposed to analyze up For groups that do not choose to
activity involved in stage 1 is not to 5 months of claims data on a rolling participate in stage 1 of the election
required, but a resource available to solo basis, in which virtual group eligibility process (that is, the group does not
practitioners and groups with 10 or determinations for each TIN would be request an eligibility determination), we
fewer eligible clinicians. Solo updated and made available monthly will make an eligibility determination
practitioners and groups that engage in (82 FR 30030). We noted that an during stage 2 of the election process. If
stage 1 and are determined eligible for eligibility determination regarding TIN a group began the election process at
virtual group participation would size is based on a relative point in time stage 2 and if its TIN size is determined
proceed to stage 2; otherwise, solo within the 5-month virtual group not to exceed 10 eligible clinicians and
practitioners and groups that do not eligibility determination period, and not not excluded based on the low-volume
engage in any activity during stage 1 made at the end of such 5-month threshold exclusion at the group level,
would begin the election process at determination period. the group is determined eligible to
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stage 2. Engaging in stage 1 would If at any time a TIN is determined to participate in MIPS as part of a virtual
provide solo practitioners and groups be eligible to participate in MIPS as part group, and such virtual group eligibility
with the option to confirm whether or of a virtual group, the TIN would retain determination status would be retained
not they are eligible to join or form a that status for the duration of the for the duration of the election period
virtual group before going to the lengths election period and the applicable and applicable performance period.
of executing formal written agreements, performance period. TINs could Stage 2 pertains to virtual group
submitting a formal election determine their status by contacting formation. For stage two, we proposed
registration, allocating resources for their designated TA representative; the following (82 FR 30031):

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TINs comprising a virtual group each TIN participating in a virtual group provided virtual groups with an
must establish a written formal that are excluded from MIPS in order to opportunity to make an election prior to
agreement between each member of a ensure that such NPIs would not receive the publication of our final rule. On
virtual group prior to an election a MIPS payment adjustment or, when October 11, 2017, the election period
( 414.1315(c)(2)(i)). applicable and when information is began and we issued information
On behalf of a virtual group, the available, would receive a payment pertaining to the start date of the
official designated virtual group adjustment based on a MIPS APM election process via subregulatory
representative must submit an election scoring standard; calculate the low- guidance, which can be accessed on the
by December 1 of the calendar year prior volume threshold at the individual and CMS Web site at https://www.cms.gov/
to the start of the applicable group levels in order to determine Medicare/Quality-Initiatives-Patient-
performance period whether or not a solo practitioner or Assessment-Instruments/Value-Based-
( 414.1315(c)(2)(ii)). Such election will group is eligible to participate in MIPS Programs/MACRA-MIPS-and-APMs/
occur via email to the Quality Payment as part of a virtual group; and notify MACRA-MIPS-and-APMs.html. As
Program Service Center using the virtual groups as to whether or not they discussed in section II.C.4.e. of this final
following email address for the 2018 are considered official virtual groups for rule with comment period, we are
and 2019 performance periods: MIPS_ the applicable performance period. For extending the virtual group election.
VirtualGroups@cms.hhs.gov. virtual groups that are determined to
The submission of a virtual group Virtual groups would have from October
have met the virtual group formation
election must include, at a minimum, 11, 2017 to December 31, 2017 to make
criteria and identified as an official
information pertaining to each TIN and an election for the 2018 performance
virtual group participating in MIPS for
NPI associated with the virtual group an applicable performance period, we year. However, any MIPS eligible
and contact information for the virtual would contact the official designated clinicians applying to be a virtual group
group representative virtual group representative via email that does not meet all finalized virtual
( 414.1315(c)(2)(iii)). A virtual group notifying the virtual group of its official group requirements would not be
representative would submit the virtual group status and issuing a virtual permitted to participate in MIPS as a
following type of information: Each TIN group identifier for performance (as virtual group.
associated with the virtual group; each described in section II.C.4.c. of this final As previously noted, solo
NPI associated with a TIN that is part of rule with comment period) that would practitioners and groups participating in
the virtual group; name of the virtual accompany the virtual groups a virtual group would have the size of
group representative; affiliation of the submission of performance data during their TIN determined for eligibility
virtual group representative to the the submission period. purposes. We recognized that the size of
virtual group; contact information for As we engaged in various discussions a TIN may fluctuate during a
the virtual group representative; and with stakeholders during the performance period with eligible
confirmation through acknowledgment rulemaking process through listening clinicians and/or MIPS eligible
that a formal written agreement has sessions and user groups, stakeholders clinicians joining or leaving a group. For
been established between each member indicated that many solo practitioners solo practitioners and groups that are
of the virtual group (solo practitioner or and small groups have limited resources determined eligible to form or join a
group) prior to election and each and technical capacities, which may virtual group based on the one-time
eligible clinician in the virtual group is make it difficult for the entities to form determination per applicable
aware of participating in MIPS as a virtual groups without sufficient time performance period, any new eligible
virtual group for an applicable and technical assistance. Depending on clinicians or MIPS eligible clinicians
performance period. Each party to the the resources and technical capacities of that join the TIN during the
virtual group agreement must retain a the entities, stakeholders conveyed that performance period would participate
copy of the virtual groups written it may take entities 3 to 18 months to in MIPS as part of the virtual group. In
agreement. We noted that the virtual prepare to participate in MIPS as a
such cases, we recognized that a solo
group agreement is subject to the MIPS virtual group. The majority of
data validation and auditing practitioner or group may exceed 1
stakeholders indicated that virtual
requirements as described in section eligible clinician or 10 eligible
groups would need at least 6 to 12
II.C.9.c. of this final rule with comment clinicians, as applicable, associated
months prior to the start of the CY 2018
period. performance period to form virtual with its TIN during an applicable
Once an election is made, the groups, prepare health IT systems, and performance period, but such solo
virtual group representative must train staff to be ready for the practitioner or group would have been
contact their designated CMS contact to implementation of virtual group related determined eligible to form or join a
update any election information that activities by January 1, 2018. virtual group given that the TIN did not
changed during an applicable We recognized that for the first year have more than 1 eligible clinician or 10
performance period at least one time of virtual group formation and eligible clinicians, as applicable,
prior to the start of an applicable implementation prior to the start of the associated with its TIN at the time of
submission period ( 414.1315(c)(2)(iv)). CY 2018 performance period, the election. As previously noted, the
Virtual groups will use the Quality timeframe for virtual groups to make an virtual group representative would need
Payment Program Service Center as election by registering would be to contact the Quality Payment Program
their designated CMS contact; however, relatively short, particularly from the Service Center to update the virtual
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we will define this further in date we issue the publication of a final groups information that was provided
subregulatory guidance. rule toward the end of the 2017 calendar during the election period if any
For stage 2 of the election process, we year. To provide solo practitioners and information changed during an
would review all submitted election groups with 10 or fewer eligible applicable performance period at least
information; confirm whether or not clinicians with additional time to one time prior to the start of an
each TIN within a virtual group is assemble and coordinate resources, and applicable submission period (for
eligible to participate in MIPS as part of form a virtual group prior to the start of example, include new NPIs who joined
a virtual group; identify the NPIs within the CY 2018 performance period, we a TIN that is part of a virtual group).

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Virtual groups must re-register before performance period as technically codifying at 414.1315(b) that,
each performance period. feasible. beginning with performance periods
The following is a summary of the Comment: A few commenters occurring in 2018, a solo practitioner, or
public comments received regarding our indicated that solo practitioners and group of 10 or fewer eligible clinicians
proposed election process for virtual groups should have the option of electing to be in a virtual group must
groups. leaving a virtual group during the make their election by December 31 of
Comment: Generally, all commenters performance period or allow a virtual the calendar year preceding the
expressed support for the technical group to remove a solo practitioner or applicable performance period.
assistance infrastructure and two-stage group for non-compliance or low
performance. f. Virtual Group Agreements
election process.
Response: We appreciate the support Response: We note that the statute As noted in section II.C.4.a. of this
from commenters. specifies that a virtual group election final rule with comment period, section
cannot be changed during the 1848(q)(5)(I)(iii)(IV) of the Act provides
Comment: A majority of commenters
performance period, and such election that the virtual group election process
expressed concern regarding the
would remain for the duration of the must provide for formal written
election deadline of December 1, while
performance period. agreements among individual MIPS
several commenters recommended that
Comment: A few commenters eligible clinicians (solo practitioners)
an election deadline be established
requested that CMS allow virtual group and groups electing to be a virtual
during the performance period in order agreements to be executed during the group. We proposed that each virtual
for virtual groups to have the adequate performance period in order to provide group member (that is, each solo
and necessary time to prepare for the the virtual group parties with time to practitioner or group) would be required
implementation of virtual groups, establish goals and objectives, build to execute formal written agreements
including the establishment and relationships with each other, and with each other virtual group member to
execution of formal written agreements identify additional agreement ensure that requirements and
and coordination within virtual groups provisions that may be necessary to expectations of participation in MIPS
to address issues pertaining to include in order to meet program are clearly articulated, understood, and
interoperability, measure selection, data requirements. agreed upon (82 FR 30032 through
collection and aggregation, measure Response: We note that section 30033). We noted that a virtual group
specifications, workflows, resources, 1848(q)(5)(I)(iii)(I) and (IV) of the Act may not include a solo practitioner or
and other related items. A few provides that the virtual group election group as part of the virtual group unless
commenters recommended an election process must require an individual an authorized person of the TIN has
deadline of June 30 to align with the MIPS eligible clinician or group electing executed a formal written agreement.
election deadline for groups and virtual to be in a virtual group to make their During the election process and
groups to register to use the CMS Web election prior to the start of the submission of a virtual group election,
Interface and/or administer the CAHPS applicable performance period, and a designated virtual group
for MIPS survey. include requirements providing for representative would be required to
Response: We appreciate the feedback formal written agreements among confirm through acknowledgement that
from commenters regarding the election individual MIPS eligible clinicians and an agreement is in place between each
deadline of December 1 and note that groups electing to be a virtual group. member of the virtual group. An
section 1848(q)(5)(I)(iii)(I) of the Act Thus, we are not authorized to establish agreement would be executed for at
provides that the virtual group election an agreement deadline during the least one performance period. If an NPI
process must require an individual performance period. However, we note joins or leaves a TIN, or a change is
MIPS eligible clinician or group electing that the parties to a virtual group made to a TIN that impacts the
to be in a virtual group to make their agreement would not be precluded from agreement itself, such as a legal business
election prior to the start of the amending their agreement during the name change, during the applicable
applicable performance period. Given performance period, which enables performance period, a virtual group
that the CY performance period for the them to incorporate any additional would be required to update the
quality and cost performance categories agreement provisions that they later agreement to reflect such changes and
begins on January 1, a solo practitioner identify as necessary. A virtual group submit changes to CMS via the Quality
or group electing to be in a virtual group representative would notify CMS of the Payment Program Service Center.
would need to make their election prior implementation and execution of an We proposed, at 414.1315(c)(3), that
to January 1. As a result, we are amended virtual group agreement. a formal written agreement between
modifying our proposed election Final Action: After consideration of each member of a virtual group must
deadline by extending it to December 31 the public comments received, we are include the following elements:
of the calendar year preceding the finalizing the following policies. We are Expressly state the only parties to
applicable performance period. We note codifying at 414.1315(a) that a solo the agreement are the TINs and NPIs of
that our proposed election deadline of practitioner or a group of 10 or fewer the virtual group (at 414.1315(c)(3)(i)).
December 1 was intended to allow us to eligible clinicians must make their For example, the agreement may not be
notify virtual groups of their official election to participate in MIPS as a between a virtual group and another
status prior to the start of the virtual group prior to the start of the entity, such as an independent practice
performance period. With the applicable performance period and association (IPA) or management
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modification we are finalizing for the cannot change their election during the company that in turn has an agreement
election deadline of December 31, it is performance period; and codifying at with one or more TINs within the
not operationally feasible for us to 414.1315(c) a two-stage virtual group virtual group. Similarly, virtual groups
notify virtual groups of their official election process, stage 1 of which is should not use existing contracts
virtual group status prior to the start of optional, for the applicable 2018 and between TINs that include third parties.
the performance period. However, we 2019 performance periods. We are Be executed on behalf of the TINs
intend to notify virtual groups of their finalizing a modification to our and the NPIs by individuals who are
official status as close to the start of the proposed election period deadline by authorized to bind the TINs and the

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NPIs, respectively at 18, 2017. OMB approved the ICR on each such eligible clinician to be a party
414.1315(c)(3)(ii)). September 27, 2017 (OMB control to the virtual group agreement. In
Expressly require each member of number 09381343). The model formal addition, we agree that it is
the virtual group (including each NPI written agreement is not required, but unnecessarily burdensome to require
under each TIN) to agree to participate serves as a template that virtual groups each solo practitioner or group that
in MIPS as a virtual group and comply could utilize in establishing an wishes to be part of a virtual group to
with the requirements of the MIPS and agreement with each member of a have a separate agreement with every
all other applicable laws and regulations virtual group. Such agreement template other solo practitioner or group that
(including, but not limited to, federal will be made available via subregulatory wishes to be part of the same virtual
criminal law, False Claims Act, anti- guidance. Each prospective virtual group. We do not believe the statute
kickback statute, civil monetary group member should consult their own compels such a requirement; a single
penalties law, the Health Insurance legal and other appropriate counsel as agreement among all solo practitioners
Portability and Accountability Act of necessary in establishing the agreement. and groups forming a virtual group is
1996, and physician self-referral law) (at We want to ensure that all eligible sufficient to implement the statutory
414.1315(c)(3)(iii)). clinicians who bill through the TINs requirement. Accordingly, we have
Require each TIN within a virtual that are components of a virtual group revised the regulation text at
group to notify all NPIs associated with are aware of their participation in a 414.1315(c)(3) to clarify that the
the TIN of their participation in the virtual group. We want to implement an parties to a formal written virtual group
MIPS as a virtual group (at approach that considers a balance agreement must be only the groups and
414.1315(c)(3)(iv)). between the need to ensure that all solo practitioners (as identified by name
Set forth the NPIs rights and eligible clinicians in a group are aware of party, TIN, and NPI) that compose the
obligations in, and representation by, of their participation in a virtual group virtual group. We note that we are
the virtual group, including without and the minimization of administration modifying our proposals for greater
limitation, the reporting requirements burden. clarity.
and how participation in MIPS as a We solicited public comment on these We recognize that our proposals
virtual group affects the ability of the proposals and on approaches for virtual regarding virtual group agreements as
NPI to participate in the MIPS outside groups to ensure that all eligible well as other virtual group matters used
of the virtual group (at clinicians in a group are aware of their the term member of a virtual group
414.1315(c)(3)(v)). participation in a virtual group. inconsistently. In some places, we used
Describe how the opportunity to The following is a summary of the the term to refer only to the components
receive payment adjustments will public comments received regarding our of the virtual group (that is, the solo
encourage each member of the virtual proposal to require formal written practitioners and groups that can form
group (including each NPI under each agreement between each member of a a virtual group), while in other places
TIN) to adhere to quality assurance and virtual group. we used the term to mean both the
improvement (at 414.1315(c)(3)(vi)). Comment: Several commenters components of the virtual group and the
Require each member of the virtual expressed support for the proposed eligible clinicians billing through a TIN
group to update its Medicare enrollment provisions that virtual groups would that is a component of the virtual group.
information, including the addition and need to include as part of the formal We believe that some of the perceived
deletion of NPIs billing through a TIN written agreement establishing a virtual burden of the requirement for a virtual
that is part of a virtual group, on a group. group agreement was due to the
timely basis in accordance with Response: We appreciate the support ambiguous use of this terminology.
Medicare program requirements and to from commenters. Wherever possible, we modified our
notify the virtual group of any such Comment: A few commenters proposals to ensure that they
changes within 30 days after the change expressed concern regarding the burden appropriately distinguishes between the
(at 414.1315(c)(3)(vii)). associated with the agreements required components of a virtual group and the
Be for a term of at least one for virtual group implementation and eligible clinicians billing through a TIN
performance period as specified in the execution. One commenter indicated that is a component of a virtual group.
formal written agreement (at that the formal written agreement Comment: One commenter expressed
414.1315(c)(3)(viii)). process, while essential to allow for data support for the proposed agreement
Require completion of a close-out capture, poses administrative burden provision that would require the parties
process upon termination or expiration and other complexities when utilizing to a virtual group agreement to be only
of the agreement that requires the TIN multiple submission mechanisms. solo practitioners and groups (not third
(group part of the virtual group) or NPI Response: We note that section parties), while another commenter did
(solo practitioner part of the virtual 1848(q)(5)(I)(iii)(IV) of the Act provides not support such provision and
group) to furnish, in accordance with that the virtual group election process indicated that many small practices
applicable privacy and security laws, all must provide for formal written have joined IPAs to provide centralized
data necessary in order for the virtual agreements among MIPS eligible support for quality improvement
group to aggregate its data across the professionals (that is, individual MIPS training, health technology support,
virtual group (at 414.1315(c)(3)(ix)). eligible clinicians and groups) that elect reporting, and analytics needed for
On August 18, 2017, we published a to be a virtual group. As such, we do not success under payment reform programs
30-day Federal Register notice (82 FR believe that our proposal to require a such as the Quality Payment Program.
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39440) announcing our formal written agreement governing the virtual The commenter also indicated that IPAs
submission of the information collection group is excessively burdensome. could serve as the administrator of a
request (ICR) for the virtual group However, although we believe the virtual group by collecting and
election process to OMB, which agreements should identify each eligible submitting data on behalf of the virtual
included a model formal written clinician billing under the TIN of a group and requested that CMS eliminate
agreement, and informing the public on practice within the virtual group, we the requirement for all members of a
its additional opportunity to review the have concluded that it would be virtual group to execute a single joint
ICR and submit comments by September unnecessarily burdensome to require agreement and expand the allowable

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scope of the agreements by permitting each party to collectively meet the unaware of their participation in a
IPAs to sign a virtual group agreement program requirements under MIPS. We Medicare Shared Savings Program ACO
with each member of a virtual group. reiterate that the statute requires formal regardless of the ACOs obligation to
Response: For purposes of written agreements to between each solo notify each NPI via direct
participation in MIPS as a virtual group, practitioner and group forming the communication. We considered directly
we note that eligible clinicians within a virtual group. Individuals billing under notifying all NPIs regarding their
virtual group are collectively assessed the TIN of a party to a virtual group are participation in MIPS as part of a virtual
and scored across each performance collectively assessed and scored across group, but based on our experience
category based on applicable measures each performance category based on under the Medicare Shared Savings
and activities that pertain to the applicable measures and activities that Program, we do not believe that such
performance of all TINs and NPIs within pertain to the performance of all TINs action would be an effective way of
a virtual group. Each TIN and NPI and NPIs within a virtual group. Each ensuring that each NPI is aware of his
within a virtual group has an integral TIN and NPI within a virtual group has or her TIN being part of a virtual group.
role in improving quality of care and an integral role in improving quality of We believe that communication within
health outcomes, and increasing care care and health outcomes, and a TIN is imperative and the crux of
coordination. As such, we believe it is increasing care coordination. As such, ensuring that each NPI is aware of his
appropriate prohibit third parties from we believe it is appropriate to require
becoming parties to a virtual group or her participation in MIPS as part of
agreements to only be between solo
agreement. However, we note that a virtual group. As part of the virtual
practitioners and groups and not
virtual groups are not precluded from group election process, we will notify
include third parties. However, we note
utilizing, or executing separate that virtual groups are not precluded each virtual group representative
agreements with, third parties to from utilizing, or executing separate regarding the official status of the
provide support for virtual group agreements with, third parties to virtual group. We will also require each
implementation. provide support for virtual group TIN within a virtual group to notify all
Comment: To minimize the implementation. NPIs associated with the TIN of their
administrative burden, one commenter Comment: One commenter requested participation in the MIPS as a virtual
suggested that CMS not require all that CMS clarify the parameters group.
agreement requirements to be met in surrounding the proposed agreement Comment: One commenter expressed
freestanding agreements. The provision that requires agreements to be support for one of the proposed
commenter noted that the agreement executed on behalf of the TINs and the agreement provisions that would set
could be an addendum to existing NPIs by individuals who are authorized forth the NPIs rights and obligations in,
contracts to eliminate the need to draft to bind the TINs and the NPIs, and how and representation by, the virtual group.
an independent agreement, unless CMS would evaluate the criterion in As part of the process for establishing an
necessary. such provision when reviewing written agreement, the commenter, as well as
Response: We consider an existing agreements. other commenters, requested that CMS
contract to mean a contract that was Response: If a solo practitioner (or his allow virtual groups to discuss with all
established and executed prior to the or her professional corporation) is a participants in the virtual group the
formation of a virtual group. Depending party to a virtual group agreement, the ways in which the virtual group would
on the parties to an existing contract, solo practitioner could execute the meet the requirements for each
freestanding virtual group agreements agreement individually or on behalf of performance category, the type of
may not be necessary. For example, if an his or her professional corporation. We
submission mechanism(s) the virtual
existing contract was established recognize that groups (TINs) have
between two or more TINs prior to the group intends to utilize, the timelines
varying administrative and operational
formation of a virtual group and such for aggregating data across the TINs
infrastructures. In general, one or more
TINs formed a virtual group among within the virtual group and for data
officers, agents, or other authorized
themselves, the required provisions of a submission, and the assessment and
individuals of a group would have the
virtual group agreement could be authority to legally bind the group. The scoring of performance and application
included in the existing contract as an parties to a virtual group agreement of the MIPS payment adjustment.
addendum as long as the parties to the should ensure that the agreement is Another commenter requested that the
existing contract include each TIN executed only by appropriately agreements include other elements such
within the virtual group and all other authorized individuals. as requiring participation in
requirements are satisfied prior to the Comment: One commenter expressed improvement activities, use of EHR, and
applicable performance period. support for the proposed agreement data sharing workflows, and suggested
However, if the existing contract is with provision that would require NPIs that CMS provide guidance on specific
a third party intermediary or does not billing under a TIN in a virtual group to efficiencies and improvement goals that
include each TIN within the virtual agree to participate in MIPS as a virtual a virtual group could support and
group, the virtual group agreement group, and urged CMS to notify, by a encourage virtual groups to create a plan
could not be effectuated as an means of direct communication, each for achieving those goals as a virtual
addendum to the existing contract. NPI regarding his or her participation in group. A commenter suggested that the
We recognize that including virtual MIPS as part of a virtual group prior to model agreement include provisions
group agreement provisions as an the performance period. related to a mutual interest in quality
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addendum to an existing contract may Response: We appreciate the support performance, shared responsibility in
reduce administrative burden and in from the commenter. We believe that it decision making, a meaningful way to
certain circumstances such an is critical for each eligible clinician in effectively use data to drive
addendum can be incorporated to an a virtual group to be aware of his or her performance, and a mechanism to share
existing contract. However, we do participation in MIPS as part of a virtual best practices within the virtual group.
believe it is critical that the inclusion of group. Based on our experience under Another commenter requested for CMS
such provisions as an addendum does the Medicare Shared Savings Program, to develop a checklist for interested
not limit or restrict the responsibility of we found that NPIs continued to be TINs to assist them in understanding the

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requirements pertaining a virtual group performance period. Virtual groups have makes it difficult to identify specific
agreement. the flexibility to include other elements requirements pertaining to the inclusion
Response: For the successful in an agreement. Each virtual group will of administration and operationalization
implementation of virtual groups, we be unique, and as a result, we encourage of health IT components in a virtual
believe that it is critical for everyone virtual groups to establish and execute group agreement that would be
participating in a virtual group an agreement that guides how a virtual universally applicable to any virtual
(including the individuals billing under group would meet its goals and group composition, while maintaining
the TIN of a group) to understand their objectives, and program requirements. the flexibility and discretion afforded to
rights and obligations in a virtual group. Some virtual groups may elect to virtual groups in establishing additional
We believe that virtual groups should include a provision that outlines the elements for their agreements that meet
have the flexibility to identify implications of a solo practitioner or the needs of virtual groups. We
additional requirements that would group failing to meet the elements of an recognize that each TIN within a virtual
facilitate and guide a virtual group as it agreement. We will also require such group will need to coordinate within the
works to achieve its goals and meet agreements to describe how the virtual group to address issues
program requirements. We note that the opportunity to receive payment pertaining to interoperability, data
model agreement serves as a template adjustments will encourage each collection, measure specifications,
that virtual groups could utilize in member of the virtual group (and each workflows, resources, and other related
establishing a virtual group agreement, NPI under each TIN in the virtual items, and believe that a virtual group
and could include other elements that group) to adhere to quality assurance is the most appropriate entity to
would meet the needs of the virtual and improvement. determine how it will prepare,
group to ensure that each TIN and NPI Comment: One commenter implement, and execute the functions of
within a virtual group are collectively recommended that virtual group the virtual group to meet the
and collaboratively working together. agreements contain similar elements requirements for each performance
We encourage the parties to a virtual used in agreements by the private category. We believe that our proposed
group agreement to actively engage in sector, which would address factors agreement elements provide a critical
discussions with eligible clinicians to pertaining to health IT and foundation for virtual group
develop a strategic plan, identify administrative and operationalization implementation, which establishes a
resources and needs, and establish components such as: Requiring the clear responsibility and obligation of
processes, workflows, and other tools as establishment of a plan for integrating each NPI to the virtual group for the
they prepare for virtual group reporting. each virtual group components health duration of an applicable performance
To support the efforts of solo IT (for example, EHRs, patient registries, period.
practitioners and groups with 10 or and practice management systems), Comment: Many commenters
fewer eligible clinicians in virtual group including a timeline to work with health expressed concern regarding the
implementation, we intend to publish a IT vendors on such integration, if timeframe virtual groups would have to
virtual group toolkit that provides applicable; requiring component of a make an election and establish
information pertaining to requirements virtual group to serve a common patient agreements. The commenters indicated
and outlines the steps a virtual group population and provide a list of that the election period is very
would pursue during an the election hospitals and/or facilities with which restrictive and does not provide
process. they have an affiliation and a list of interested solo practitioners and groups
Comment: One commenter requested counties in which they would be active; with sufficient time to meet and execute
that the agreement be a 1-year term and and determining how a virtual group the required elements of an agreement
renewable thereafter. would be staffed and governed by and work through all of the necessary
Response: We note that an agreement identifying staff allocations to details in forming and implementing a
will need to be executed for at least one organizational leadership, clinical virtual group. The commenters also
performance period. However, with leadership, practice consultants, and IT noted that contractual agreements
virtual groups being required to be resources. between NPIs and TINs often take
assessed and scored across all four Response: We recognize that different several months, at least, to negotiate and
performance categories, and the quality sectors may have established finalize. A few commenters indicated
and cost performance categories having agreements with various elements to that interested solo practitioners and
a calendar year performance period (at facilitate and assure attainment of groups would not have adequate time to
414.1320), we clarify that a virtual program goals and objectives, which make informed decisions regarding
group agreement would need to be may serve as a useful tool to virtual virtual group participation. The
executed for least a 1-year term. Virtual groups. We encourage virtual groups to commenters noted that it would be
groups have the flexibility to establish a assess whether or not their agreement helpful to have the virtual group
new agreement or renew the execution should include other elements in agreement template available for review
of an existing agreement for the addition to our proposed agreement and comment in advance. One
preceding applicable performance provisions. Virtual groups have the commenter indicated that the lack of
period. flexibility to identify other elements that virtual group requirements at this early
Comment: One commenter requested would be critical to include in an stage of the Quality Payment Program
that the virtual group agreements clearly agreement specific to their particular causes a lack of clarity and stability for
specify the repercussions of an eligible virtual group. We believe it is essential eligible clinicians and/or groups
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clinician or group within a virtual group to continue to provide virtual groups interested in forming virtual groups.
who fails to report as part of the virtual with the flexibility to establish Response: In order to provide support
group. agreements that will most appropriately and reduce burden, we intend to make
Response: We believe that the reflect the unique characteristics of a TA available, to the extent feasible and
proposed provisions of a virtual group virtual group. appropriate, to support clinicians who
agreement provide a foundation that Also, we note that different TINs, choose to come together as a virtual
sets forth the responsibilities and particularly small practices, may have group. Clinicians can access the TA
obligations of each party for a access to different resources, which infrastructure and resources that they

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may already be utilizing. In section concern that while such steps are group practice (as defined for
II.C.4.e. of this final rule with comment necessary to ensure the success of purposes of the physician self-referral
period, we establish a two-stage virtual virtual groups, such steps could raise law) is a separate legal issue that is not
group election process, stage 1 of which issues regarding compliance with governed by this final rule with
is optional, for performance periods certain fraud and abuse laws, comment period. We recognize that a
occurring in 2018 and 2019 (82 FR particularly the physician self-referral virtual group may include multiple
30030 through 30032). Stage 1 pertains law (section 1877 of the Act) and the clinician practices and that the
to virtual group eligibility anti-kickback statute (section 1128B(b) clinicians in one practice may refer
determinations, and stage 2 pertains to of the Act). The commenters requested patients for services that will be
virtual group formation. During stage 1, that CMS assess the potential risks furnished by other practices in the
solo practitioners and groups have the virtual groups may have under the virtual group. However, we believe that
option to contact their designated TA physician self-referral law and whether the virtual group arrangement can be
representative in order to obtain or not a regulatory exception would be structured in a manner that both
information pertaining to virtual groups necessary to successfully implement complies with an existing physician
and/or determine whether or not they and maximize the advantages of the self-referral law exception and does not
are eligible, as it relates to the practice virtual group option. One commenter violate the anti-kickback statute. We
size requirement. Clinicians who do not noted that parties to a virtual group note that the issuance of guidance,
elect to contact their designated TA agreement may want to enter into exceptions, or safe harbors regarding the
representative would still have the financial arrangements with each other physician self-referral law or the anti-
option of contacting the Quality to maximize the benefit of the virtual kickback statute is beyond the scope of
Payment Program Service Center to group (for example, pay for one party to this rulemaking, and MACRA does not
obtain information pertaining to virtual organize and submit all measures on authorize the Secretary to waive any
groups. behalf of all the virtual group parties) fraud and abuse laws for MIPS. Finally,
We recognize that the election period, and that such an arrangement may HHS is not authorized to interpret or
including the timeframe virtual groups result in some eligible clinicians being provide guidance regarding the anti-
would have to establish and implement unable to refer patients to other trust laws.
the virtual group agreement, and the participants in the virtual group without Comment: Several commenters
timeline for establishing virtual group running afoul of the physician self- supported the development of a model
policies in this final rule with comment referral law, unless CMS established an agreement. One commenter indicated
period is short and imposes certain exception for virtual groups. A few that the model agreement lacked the
potential barriers for virtual group commenters requested that the Secretary details necessary to enable virtual
formation and limitations for the first exercise prosecutorial discretion by not groups to cover all required criteria and
year of virtual group implementation enforcing the anti-kickback statute and urged CMS to supply a template that is
that we are not able to eliminate due to the physician self-referral law for inclusive of needed detail and
statutory constraints, such as the activities involving the development instructions.
requirement for virtual groups to make and operation of a virtual group. Response: We appreciate the support
an election made prior to an applicable Many commenters expressed from commenters. In regard to the
performance period. In order to mitigate concerns regarding the lack of model agreement, we established such a
some of the challenges, we developed a information and clarity pertaining to the template in order to reduce the burden
model agreement to serve as a template interaction between virtual groups and of virtual groups having to develop an
that could be utilized by virtual groups the physician self-referral law, anti- agreement. On August 18, 2017, we
as they prepare for the implementation kickback statute, and antitrust law. The published a 30-day Federal Register
of virtual groups and are finalizing a commenters requested that CMS clarify notice (82 FR 39440) announcing our
modification to the election period the program integrity obligations of formal submission of the ICR for the
deadline by extending it to December virtual groups, issue safe harbors, and virtual group election process to OMB,
31, which can be accessed on the CMS publish guidance outlining how the which included a model formal written
Web site at https://www.cms.gov/ physician self-referral law, anti- agreement, and informing the public on
Medicare/Quality-Initiatives-Patient- kickback statute, and antitrust law apply its additional opportunity to review the
Assessment-Instruments/Value-Based- to virtual groups. The commenters information collection request and
Programs/MACRA-MIPS-and-APMs/ asserted that this was needed in order submit comments by September 18,
MACRA-MIPS-and-APMs.html. In this for solo practitioners and groups to 2017. OMB approved the ICR on
final rule with comment period, we are maintain safeguards against fraud and September 27, 2017 (OMB control
establishing virtual group policies for abuse while soliciting partners to form number 09381343). The utilization of
the 2018 and 2019 performance periods. a virtual group and working toward our model agreement is not required,
Solo practitioners and groups with 10 or common MIPS goals. but serves as a tool that can be utilized
fewer eligible clinicians that are not able Response: Nothing in this final rule by virtual groups. Each prospective
to form virtual groups for the 2018 with comment period changes the party to a virtual group agreement
performance period should have application of the physician self-referral should consult their own legal and other
sufficient time to prepare and law, anti-kickback statute, or anti-trust appropriate counsel as necessary in
implement requirements applicable to laws. We note that a group practice as establishing the agreement. We note that
virtual groups for the 2019 performance defined for purposes of the physician the received comments pertaining to the
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period. self-referral law is separate and distinct content of the model agreement are out
Comment: A majority of commenters from a virtual group as defined in this of scope for this final rule with
indicated that virtual group formation final rule. A virtual group may, but is comment period.
involves preparing health IT systems, not required, to include a group Final Action: After consideration of
training staff to be ready for practice as defined for purposes of the public comments received, we are
implementation, sharing and physician self-referral law. Whether an finalizing with modification our
aggregating data, and coordinating entity that is assigned a TIN and is proposal at 414.1315(c)(3) regarding
workflows. The commenters expressed included in a virtual group should be a virtual group agreements. This final rule

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with comment period requires a formal assurance and improvement (at Individual eligible clinicians and
written agreement between each solo 414.1315(c)(3)(vi)). individual MIPS eligible clinicians who
practitioner and group that composes a Requires each party to the are part of a TIN participating in MIPS
virtual group; the revised regulation text agreement to update its Medicare at the virtual group level must aggregate
makes it clear the formal written virtual enrollment information, including the their performance data across multiple
group agreement must identify, but need addition and deletion of NPIs billing TINs in order for their performance to
not include as parties to the agreement, through its TIN, on a timely basis in be assessed as a virtual group (at
all eligible clinicians who bill under the accordance with Medicare program 414.1315(d)(3)).
TINs that are components of the virtual requirements and to notify the virtual MIPS eligible clinicians that elect to
group. The requirement to execute a group of any such changes within 30 participate in MIPS at the virtual group
formal written virtual group agreement days after the change (at level would have their performance
ensures that requirements and 414.1315(c)(3)(vii)). assessed at the virtual group level across
expectations of participation in MIPS Is for a term of at least one all four MIPS performance categories (at
are clearly articulated, understood, and performance period as specified in the 414.1315(d)(4)).
agreed upon. We are finalizing our formal written agreement (at Virtual groups would need to
proposal that a virtual group agreement 414.1315(c)(3)(viii)). adhere to an election process
must be executed on behalf of a party Requires completion of a close-out established and required by CMS (at
to the agreement by an individual who process upon termination or expiration 414.1315(d)(5)).
is authorized to bind the party. For of the agreement that requires each The following is a summary of the
greater clarity, we are finalizing with party to the virtual group agreement to public comments received regarding our
modification our proposals at furnish, in accordance with applicable proposed virtual group reporting
414.1315(c)(3) that a formal written privacy and security laws, all data requirements.
agreement between each member of a necessary in order for the virtual group Comment: Many commenters
virtual group must include the to aggregate its data across the virtual generally supported our proposed
following elements: group (at 414.1315(c)(3)(ix)). reporting requirements for virtual
During the election process and groups.
Identifies the parties to the
submission of a virtual group election, Response: We appreciate the support
agreement by name of party, TIN, and
a designated virtual group from the commenters.
NPI, and includes as parties to the Comment: One commenter expressed
representative will be required to
agreement only the groups and solo support of our proposed virtual group
confirm through acknowledgement that
practitioners that compose the virtual reporting requirements and indicated
an agreement is in place between all
group (at 414.1315(c)(3)(i)). that a majority of practicing vascular
solo practitioners and groups that
Is executed on behalf of each party surgeons are part of private practices,
compose the virtual group. An
by an individual who is authorized to including groups of 10 or fewer eligible
agreement will be executed for at least
bind the party (at 414.1315(c)(3)(ii)). clinicians, and would benefit from
one performance period. If a NPI joins
Expressly requires each member of or leaves a TIN, or a change is made to participating in MIPS as part of a virtual
the virtual group (and each NPI under a TIN that impacts the agreement itself, group. The commenter noted that the
each TIN in the virtual group) to such as a legal business name change, implementation of virtual groups would
participate in MIPS as a virtual group during the applicable performance ease burdens on small practices and
and comply with the requirements of period, a virtual group will be required eligible clinicians by allowing them to
the MIPS and all other applicable laws to update the agreement to reflect such report data together for each
and regulations (including, but not changes and submit changes to CMS via performance category, and be assessed
limited to, federal criminal law, False the Quality Payment Program Service and scored as a virtual group. Another
Claims Act, anti-kickback statute, civil Center. commenter supported our proposal that
monetary penalties law, the Health allows small practices to aggregate their
Insurance Portability and g. Virtual Group Reporting data at the virtual group level, which
Accountability Act of 1996, and Requirements would allow them to have a larger
physician self-referral law) (at As discussed in section II.C.4.d. of denominator to spread risk and mitigate
414.1315(c)(3)(iii)). this final rule with comment period, we the impact of adverse outlier situations.
Identifies each NPI under each TIN believe virtual groups should generally Response: We appreciate the support
in the virtual group and requires each be treated under the MIPS as groups. from the comment regarding our
TIN within a virtual group to notify all Therefore, for MIPS eligible clinicians proposed virtual group reporting
NPIs associated with the TIN of their participating at the virtual group level, requirements.
participation in the MIPS as a virtual we proposed at 414.1315(d) the Comment: One commenter indicated
group (at 414.1315(c)(3)(iv)). following requirements (82 FR 30033): that the reporting of performance data
Sets forth the NPIs rights and Individual eligible clinicians and for all NPIs under a TIN participating in
obligations in, and representation by, individual MIPS eligible clinicians who a virtual group, particularly non-MIPS
the virtual group, including without are part of a TIN participating in MIPS eligible clinicians who are excluded
limitation, the reporting requirements at the virtual group level would have from MIPS participation, would be a
and how participation in MIPS as a their performance assessed as a virtual regulatory burden to virtual groups.
virtual group affects the ability of the group (at 414.1315(d)(1)). Response: We do not believe that
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NPI to participate in the MIPS outside Individual eligible clinicians and requiring virtual groups to report on
of the virtual group (at individual MIPS eligible clinicians who data for all NPIs under a TIN
414.1315(c)(3)(v)). are part of a TIN participating in MIPS participating in a virtual group would
Describes how the opportunity to at the virtual group level would need to be burdensome to virtual groups. Based
receive payment adjustments will meet the definition of a virtual group at on previous feedback from stakeholders
encourage each member of the virtual all times during the performance period regarding group reporting under PQRS,
group (and each NPI under each TIN in for the MIPS payment year (at we believe that it would be more
the virtual group) to adhere to quality 414.1315(d)(2)). burdensome for virtual groups to

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determine which clinicians are MIPS aforementioned challenges in data and CAHPS for MIPS survey differ in
eligible versus not MIPS eligible and aggregation. their application to virtual groups.
remove performance data for non-MIPS Response: We appreciate the feedback Specifically, data completeness for
eligible clinicians when reporting as a from commenters and note that statute virtual groups applies cumulatively
virtual group. While entire TINs requires virtual groups to be assessed across all TINs in a virtual group. Thus,
participate in a virtual group, including and scored, and subject to a MIPS we note that there may be a case when
each NPI under a TIN, and are assessed payment adjustment as a result of TINs a virtual group has one TIN that falls
and scored collectively as a virtual participating in a virtual group under below the 60 percent data completeness
group, we note that only NPIs that meet MIPS. The statute does not authorize us threshold, which is an acceptable case
the definition of a MIPS eligible to establish additional exclusions that as long as the virtual group
clinician would be subject to a MIPS are not otherwise identified in statute. If cumulatively exceeds such threshold. In
payment adjustment. a virtual group encounters technical regard to the CMS Web Interface and
Comment: A majority of commenters challenges regarding data aggregation CAHPS for MIPS survey, sampling
did not support our proposal to require and are not able to report on measures requirements pertain to Medicare Part B
all eligible clinicians who are part of a and activities via QCDRs, qualified patients with respect to all TINs in a
TIN participating in MIPS at the virtual registries, or EHRs, virtual groups would virtual group, where the sampling
group level to aggregate their have the option of reporting via the methodology would be conducted for
performance data across multiple TINs CMS Web Interface (for virtual groups of each TIN within the virtual group and
in order for their performance to be 25 or more eligible clinicians), a CMS- then cumulatively aggregated across the
assessed and scored as a virtual group. approved survey vendor for the CAHPS virtual group. A virtual group would
The commenters expressed concerns for MIPS survey, and administrative need to meet the beneficiary sampling
that it would be burdensome for rural claims (if applicable) for the quality and threshold cumulatively as a virtual
and small practices and prohibitive for cost performance categories, and via group.
virtual groups to perform data attestation for the improvement Comment: A few commenters urged
aggregation and requested that CMS activities and advancing care CMS to set clear expectations as to how
aggregate data for virtual groups. The information performance categories. The virtual groups should submit data across
commenters indicated that the administrative claims submission performance categories and from
requirement for virtual groups to mechanism does not require virtual multiple systems while ensuring their
aggregate data across the virtual group groups to submit data for purposes of information is aggregated and reported
could be a potential barrier for virtual the quality and cost performance correctly to maximize the virtual
group participation and would be categories but the calculation of groups final score and requested that
unlikely to occur without error. One performance data is conducted by CMS. CMS provide clarity regarding virtual
commenter requested that CMS further We note that the measure reporting group reporting. One commenter
define data aggregation and clarify requirements applicable to groups are indicated that virtual group reporting
whether or not individual reports from also generally applicable to virtual can be completed through QCDRs, in
each NPI within a virtual group could groups. However, we note that the which multiple eligible clinicians in a
simply be added together for all NPIs in requirements for calculating measures virtual group could report to one place
the virtual group or if each NPIs data and activities when reporting via on the quality of care furnished to their
could be pulled from each TINs QRDA QCDRs, qualified registries, EHRs, and respective patients. The commenter
file. attestation differ in their application to noted that the commitments from CMS
Response: We appreciate the feedback virtual groups. Specifically, these and ONC regarding interoperability and
from the commenters and recognize that requirements apply cumulatively across electronic data sharing would continue
data aggregation across multiple TINs all TINs in a virtual group. Thus, virtual to further the feasibility of virtual group
within a virtual group may pose varying groups will aggregate data for each NPI reporting through EHRs in the future.
challenges. At this juncture, it is not under each TIN within the virtual group However, a few commenters requested
technically feasible for us to aggregate by adding together the numerators and clarification regarding how data can and
the data for virtual groups, but will denominators and then cumulatively should be submitted for virtual groups,
consider such option in future years. In collate to report one measure ratio at the and whether or not QCDRs and other
order to support the implementation of virtual group level. Moreover, if each clinical outcomes data registries would
virtual groups as a participation option MIPS eligible clinician within a virtual be able to assist virtual groups by
under MIPS, we intend to issue group faces a significant hardship or has sharing in the responsibility for
subregulatory guidance pertaining to EHR technology that has been aggregating data. The commenters noted
data aggregation for virtual groups. decertified, the virtual group can apply that the aggregation of data across
Comment: A few commenters for an exception to have its advancing various TINs and health IT systems may
recommended that for the first year of care information performance category be logistically difficult and complex, as
virtual group implementation, CMS reweighted. If such exception groups and health IT systems have
hold virtual groups and registries that application is approved, the virtual different ways of collecting and storing
support virtual groups harmless from groups advancing care information data and stated that data aggregation
penalties if they encounter technical performance category is reweighted to across various systems for measures and
challenges related to data aggregation. zero percent and applied to the quality activities under each performance
The commenters noted that the performance category increasing the category may not be possible if qualified
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potential penalty for technical quality performance weight from 50 registries do not have the option to
challenges in data aggregation is a percent to 75 percent. assist virtual groups.
severe 5 percent for TINs that are Additionally, the data submission Response: We appreciate the feedback
already operating on small margins and criteria applicable to groups are also from commenters and recognize that
expressed concerns that registries generally applicable to virtual groups. commenters seek clarification regarding
supporting virtual group reporting However, we note that data submission requirements for third party
would be opening themselves to completeness and sampling intermediaries such as QCDRs, qualified
potential disqualification for the requirements for the CMS Web Interface registries, and EHRs. We note that third

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party intermediaries would need to Response: We note that virtual groups group. Also, the commenter indicated
meet the same requirements established are not precluded from utilizing third that it is not clear what responsibility a
at 414.1400 and form and manner per party intermediaries such as QCDRs and qualified registry would have, if any, to
submission mechanism when qualified registries to support virtual verify if a virtual group reporting
submitting data on behalf of virtual groups in meeting virtual group through a registry has all the
groups. We intend to issue reporting requirements. We intend to appropriate legal agreements in place
subregulatory guidance for virtual issue subregulatory guidance for virtual prior to their participation in the
groups and third party intermediaries groups and third party intermediaries registry.
pertaining to data aggregation and the pertaining to data aggregation and the Response: We appreciate the
collection and submission of data. collection and submission of data. commenter expressing such concern
Comment: One commenter requested Comment: A few commenters and note that we intend to issue
clarification regarding the submission of expressed concern that the submission subregulatory guidance for virtual
data for virtual groups via EHRs. The mechanisms available to virtual groups groups and third party intermediaries
commenter indicated that while groups involve multiple layers of legal and pertaining to data aggregation and the
may already be familiar with the operational complexity. The collection and submission of data. We
reporting of quality measures via EHRs, commenters indicated that certain note that the measure reporting
the addition of the improvement registries have internal data governance requirements applicable to groups are
activities and advancing care standards, including patient safety also generally applicable to virtual
information performance categories organization requirements, that they groups. However, we note that the
adds a new level of complexity. Also, must follow when contracting with requirements for calculating measures
the commenter requested clarification single TIN participants, such that legal and activities when reporting via
regarding whether or not CMS has an agreements made between solo QCDRs, qualified registries, EHRs, and
established mechanism that would practitioners and small groups within a attestation differ in their application to
accept multiple QRDA III submissions virtual group may complicate the virtual groups. Specifically, these
for a single virtual group pertaining to registries ability to comply with those requirements apply cumulatively across
the improvement activities and requirements. The commenters all TINs in a virtual group. Thus, virtual
advancing care information performance recommended that CMS provide groups will aggregate data for each NPI
categories. The commenter indicated guidance to registries on how to handle under each TIN within the virtual group
that standards do not exist to combine data sharing among virtual groups with by adding together the numerators and
files pertaining to the improvement respect to patient safety organization denominators and then cumulatively
activities and advancing care requirements. One commenter collate to report one measure ratio at the
information performance categories expressed concern regarding how virtual group level. Moreover, if each
from disparate vendors and requested registries would be able to meet virtual MIPS eligible clinician within a virtual
clarification regarding whether or not group requirements to report a sufficient group faces a significant hardship or has
combined files would be needed for number of measures given that some EHR technology that has been
virtual groups and for CMS to issue registries may have made a variety of decertified, the virtual group can apply
guidance to vendors at least 18 months measures available for individual for an exception to have its advancing
in advance regarding development and eligible clinicians to report, but may care information performance category
implementation. need to increase the available measures reweighted. If such exception
Response: We appreciate the feedback to report in order to support virtual application is approved, the virtual
from the commenter and note that we group reporting. The commenter groups advancing care information
intend to issue additional subregulatory requested that CMS provide guidance performance category is reweighted to
guidance for third party intermediaries regarding the expectations for registries zero percent and applied to the quality
pertaining to the collection and supporting virtual group reporting, performance category increasing the
submission of data for all performance particularly when considering the role quality performance weight from 50
categories. In regard to the submission of specialty registries and the quality percent to 75 percent.
of multiple QRDA III files, our system performance category. Additionally, the data submission
is not built to allow for the submission Response: We recognize that certain criteria applicable to groups are also
of multiple QRDA III files. Groups and registries may have internal governance generally applicable to virtual groups.
virtual groups are required to submit standards complicating how they would However, we note that data
one QRDA III file for each performance support virtual groups, but note that by completeness and sampling
category. Given that virtual groups are definition, a virtual group is a requirements for the CMS Web Interface
required to aggregate their data at the combination of TINs. We appreciate the and CAHPS for MIPS survey differ in
virtual level and submit one file of data feedback from commenters and note their application to virtual groups.
per performance category, there may be that we intend to issue additional Specifically, data completeness for
circumstances that would require a subregulatory guidance for third party virtual groups applies cumulatively
virtual group to combine their files in intermediaries such as qualified across all TINs in a virtual group. Thus,
order to meet the submission registries. we note that there may be a case when
requirements. However, it should be Comment: One commenter expressed a virtual group has one TIN that falls
noted that all other measures and concern regarding how quality data below the 60 percent data completeness
activities requirements would also need would be collected, aggregated and threshold, which is an acceptable case
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to be met in order for virtual groups to displayed for solo practitioners and as long as the virtual group
meeting reporting and submission groups composing the virtual group. cumulatively exceeds such threshold. In
requirements. The commenter requested clarification regard to the CMS Web Interface and
Comment: One commenter requested regarding whether or not solo CAHPS for MIPS survey, sampling
that CMS allow QCDRs and other practitioners and groups composing the requirements pertain to Medicare Part B
clinical outcomes data registries to virtual group would be allowed to view patients with respect to all TINs in a
support virtual groups in aggregating the quality data of other solo virtual group, where the sampling
measures and activities for reporting. practitioners and groups in the virtual methodology would be conducted for

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each TIN within the virtual group and group reporting option have a transition would increase administrative burden
then cumulatively aggregated across the year for the CY 2018 and CY 2019 for virtual groups. However, we
virtual group. A virtual group would performance periods in order for solo encourage virtual groups to actively
need to meet the beneficiary sampling practitioners and groups to become engage in discussions with its members
threshold cumulatively as a virtual familiar with implementing the virtual to develop a strategic plan, select
group. In regard to the comment group reporting option as well as the measures and activities to report,
requesting clarification on whether or election process and executing identify resources and needs, and
not solo practitioners and groups agreements. The commenter requested establish processes, workflows, and
composing a virtual group would be that virtual groups have the pick your other tools as they prepare for virtual
allowed to view quality data of other pace options that were established for group reporting. Virtual groups have the
solo practitioners and groups in the the CY 2017 performance period for the flexibility to identify other elements, in
virtual group, we note that virtual CY 2018 performance period in order to addition to our proposed agreement
groups have the flexibility to determine test the virtual group option, whereby provisions, that would be critical to
if, how, and when solo practitioners and the virtual group would only need to include in an agreement specific to their
groups in the virtual group would be report one quality measure or one particular virtual group. We believe that
able to view quality data and/or data improvement activity to avoid a virtual groups should have the
pertaining to the other three negative MIPS payment adjustment. flexibility to identify additional
performance categories, in which such Response: We note that it is not requirements that would facilitate and
permissibility could be established as a permissible for virtual groups to meet guide a virtual group as it works to
provision under the virtual group the requirements established for the achieve its goals and meet program
agreement. Moreover, the establishment 2017 performance period given that requirements.
and execution of a virtual group such requirements are not applicable to Comment: One commenter
agreement is the responsibility of the the 2018 performance period. Moreover, recommended that CMS require all
parties electing to participate in MIPS as the pick your pace options were eligible clinicians within a virtual group
part of a virtual group. Health IT based on the lower performance to report on the same measure set. The
vendors or third party intermediaries threshold established for the CY 2017 commenter indicated that unifying
are not required to verify that each performance period. As discussed in measures would allow CMS to aggregate
virtual group has established and section II.C.8.c. of this final rule with numerators and denominators more
executed a prior virtual group comment period, we are finalizing a easily when calculating performance
agreement. higher performance threshold for the CY against measures.
Comment: One commenter indicated 2018 performance period, and the Response: For virtual groups that
that there would be added technical statute requires the establishment of one report via the CMS Web Interface, they
challenges for a virtual group performance threshold for a would report on all measures within the
representative when submitting on performance period, which is the same CMS Web Interface. For virtual groups
behalf of their virtual group given that for all MIPS eligible clinicians that report via other submission
he or she may face errors or warnings regardless of how or when they mechanisms, they would report on the
during submission and, due to the participate in MIPS. Year 2 same 6 measures for the quality
possibility that individual files could requirements for virtual groups are performance category. We encourage
come from various EHR vendors, that defined throughout this final rule with virtual groups to assess the types of
representative would not have authority comment period. measures and measure sets to report to
or the ability to work directly with Comment: One commenter requested ensure that they would meet the
another TINs vendor. that CMS require virtual groups to reporting requirements for the
Response: We note that virtual groups report a plan prior to the start of the applicable performance categories.
have the flexibility to determine how performance period regarding how Comment: One commenter
they would complete reporting under members of the virtual group (solo recommended that CMS develop a web-
MIPS. We believe that virtual groups practitioners and groups) would share based portal that would streamline
would need to address operational data internally, including how they reporting requirements for virtual
elements to ensure that it would meet would identify the measures that the groups. For example, CMS could model,
the reporting requirements for each virtual group would report, and share to the extent possible and appropriate,
performance category. Virtual groups NPI-level performance data on those a virtual group web-based portal on the
are able to utilize the same multiple measures with each other during the CMS Web Interface. The availability of
submission mechanisms that are performance period to facilitate a web-based portal would relieve a
available to groups. For the 2018 performance improvement. substantial burden for solo practitioners
performance period, groups and virtual Response: We appreciate the and small groups who do not have the
groups can utilize multiple submission commenter recommending requirements same level of resources as larger groups
mechanism, but only use one for virtual groups, but disagree with the to purchase and maintain the
submission mechanism per performance recommendation that would require infrastructure necessary for MIPS
category. Starting with the 2019 virtual groups to submit a report to us reporting. Moreover, the commenter
performance period, groups and virtual prior to the start of the performance indicated that a single reporting portal
groups will be able to utilize multiple period outlining how the virtual group would ease data collection burden on
submission mechanisms for each would share data internally, how the CMS, enabling the Agency to collect and
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performance category. virtual group would identify the pull data from a single source under a
Comment: One commenter measures and activities to report, and single submission mechanism rather
recommended that the virtual group share NPI-level performance data on than engaging in a more cumbersome
infrastructure be defined and tested those measures with each other during process that could require multiple data
prior to implementation and noted that the performance period to facilitate collection and submission mechanisms.
virtual group implementation does not performance improvement. We believe Response: We have developed a web-
appear to be ready for CY 2018. Another that the submission of such report prior based portal submission system that
commenter suggested that the virtual to the start of the performance period streamlines and simplifies the

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submission of data at the individual, execution of virtual groups. Also, we application is approved, the virtual
group, and virtual group level, recognize that certain solo practitioners groups advancing care information
including the utilization of multiple and groups may not be ready to form performance category is reweighted to
submission mechanisms (one virtual groups for the 2018 performance zero percent and applied to the quality
submission mechanism per performance period. performance category increasing the
category), for each performance Comment: One commenter expressed quality performance weight from 50
category. We will be issuing guidance at concern regarding how a health IT percent to 75 percent.
qpp.cms.gov pertaining to the utilization vendor would support a virtual group Additionally, the data submission
and functionality of such portal. regardless of submission mechanism, criteria applicable to groups are also
Comment: Several commenters CEHRT, registry, and/or billing claims. generally applicable to virtual groups.
requested that CMS clarify whether or The commenter indicated that having However, we note that data
not data should be de-duplicated for multiple health IT vendors and products completeness and sampling
virtual group reporting. The to support within a single virtual group requirements for the CMS Web Interface
commenters indicated that TINs already would complicate the ability to and CAHPS for MIPS survey differ in
have an issue of not being able to de- aggregate data for a final score, affect the their application to virtual groups.
duplicate patient data across different productivity of the health IT vendor in Specifically, data completeness for
health IT systems/multiple EHRs. The its effort to support the virtual groups, virtual groups applies cumulatively
commenters indicated that virtual and increase coding and billing errors. across all TINs in a virtual group. Thus,
groups need clear guidelines regarding Response: We note that virtual groups we note that there may be a case when
how to achieve accurate reporting and may elect to utilize health IT vendors a virtual group has one TIN that falls
suggested that CMS may want to and/or third party intermediaries for the below the 60 percent data completeness
consider delaying implementation of the collection and submission of data on threshold, which is an acceptable case
virtual group reporting option until all behalf of virtual groups. As discussed in as long as the virtual group
related logistics issues and solutions are section II.C.6.a.(1) of this final rule with cumulatively exceeds such threshold. In
identified. comment period, the submission regard to the CMS Web Interface and
Response: We interpret the mechanisms available to groups under CAHPS for MIPS survey, sampling
commenters reference to de- each performance category will also be requirements pertain to Medicare Part B
duplicate to mean the identification of available to virtual groups. Similarly, patients with respect to all TINs in a
unique patients across a virtual group. virtual groups will also have the same
virtual group, where the sampling
We recognize that it may be difficult to option as groups to utilize multiple
methodology would be conducted for
identify unique patients across a virtual submission mechanisms, but only one
each TIN within the virtual group and
group for the purposes of aggregating submission mechanism per performance
then cumulatively aggregated across the
performance on the advancing care category for the 2018 performance
virtual group. A virtual group would
information measures, particularly period. However, starting with the 2019
need to meet the beneficiary sampling
when a virtual group is using multiple performance period, groups and virtual
threshold cumulatively as a virtual
CEHRT systems. For 2018, virtual groups will be able to utilize multiple
group.
groups may be using systems which are submission mechanisms for each
certified to different CEHRT editions performance category. We believe that Final Action: After consideration of
further adding to this challenge. We our policies pertaining to the the public comments received, we are
consider unique patients to be availability and utilization of multiple finalizing the following virtual group
individual patients treated by a TIN submission mechanisms increases reporting requirements:
within a virtual group who would flexibility and reduces burden. Individual eligible clinicians and
typically be counted as one patient in However, we recognize that data individual MIPS eligible clinicians who
the denominator of an advancing care aggregation across at the virtual group are part of a TIN participating in MIPS
information measure. This patient may level may pose varying challenges. at the virtual group level will have their
see multiple MIPS eligible clinicians We note that the measure reporting performance assessed as a virtual group
within a TIN that is part of a virtual requirements applicable to groups are at 414.1315(d)(1).
group, or may see MIPS eligible also generally applicable to virtual Individual eligible clinicians and
clinicians at multiple practice sites of a groups. However, we note that the individual MIPS eligible clinicians who
TIN that is part of a virtual group. When requirements for calculating measures are part of a TIN participating in MIPS
aggregating performance on advancing and activities when reporting via at the virtual group level will need to
care information measures for virtual QCDRs, qualified registries, EHRs, and meet the definition of a virtual group at
group level reporting, we do not require attestation differ in their application to all times during the performance period
that a virtual group determine that a virtual groups. Specifically, these for the MIPS payment year (at
patient seen by one MIPS eligible requirements apply cumulatively across 414.1315(d)(2)).
clinician (or at one location in the case all TINs in a virtual group. Thus, virtual Individual eligible clinicians and
of TINs working with multiple CEHRT groups will aggregate data for each NPI individual MIPS eligible clinicians who
systems) is not also seen by another under each TIN within the virtual group are part of a TIN participating in MIPS
MIPS eligible clinician in the TIN that by adding together the numerators and at the virtual group level must aggregate
is part of the virtual group or captured denominators and then cumulatively their performance data across multiple
in a different CEHRT system. collate to report one measure ratio at the TINs in order for their performance to
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In regard to the suggestion provided virtual group level. Moreover, if each be assessed as a virtual group (at
by the commenter regarding the delay of MIPS eligible clinician within a virtual 414.1315(d)(3)).
the implementation of virtual groups, group faces a significant hardship or has MIPS eligible clinicians that elect to
we are not able to further postpone the EHR technology that has been participate in MIPS at the virtual group
implementation of virtual groups. We decertified, the virtual group can apply level will have their performance
recognize that there are various for an exception to have its advancing assessed at the virtual group level across
elements and factors that virtual groups care information performance category all four MIPS performance categories (at
would need to address prior to the reweighted. If such exception 414.1315(d)(4)).

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Virtual groups will need to adhere assign the virtual group score to all TIN/ determining MIPS payment adjustments
to an election process established and NPIs billing under a TIN in the virtual for these MIPS eligible clinicians using
required by CMS (at 414.1315(d)(5)). group during the performance period. the final score of their virtual group.
During the performance period, we We noted that MIPS eligible clinicians
h. Virtual Group Assessment and recognized that NPIs in a TIN that has
Scoring who are participants in both a virtual
joined a virtual group may also be group and a MIPS APM would be
As noted in section II.C.4.a. of this participants in an APM. The TIN, as assessed under MIPS as part of the
final rule with comment period, section part of the virtual group, would be virtual group and under the APM
1848(q)(5)(I)(i) of the Act provides that required to submit performance data for scoring standard as part of an APM
MIPS eligible clinicians electing to be a all eligible clinicians associated with Entity group, but would receive their
virtual group must: (1) Have their the TIN, including those participating in payment adjustment based only on the
performance assessed for the quality APMs, to ensure that all eligible APM Entity score. In the case of an
and cost performance categories in a clinicians associated with the TIN are eligible clinician participating in both a
manner that applies the combined being measured under MIPS. virtual group and an Advanced APM
performance of all the MIPS eligible APMs seek to deliver better care at who has achieved QP status, the
clinicians in the virtual group to each lower cost and to test new ways of clinician would be assessed under MIPS
MIPS eligible clinician in the virtual paying for care and measuring and as part of the virtual group, but would
group for the applicable performance assessing performance. In the CY 2017 still be excluded from the MIPS
period; and (2) be scored for the quality Quality Payment Program final rule, we payment adjustment as a result of his or
and cost performance categories based established policies to the address her QP status. We refer readers to
on such assessment for the applicable concerns we have expressed in regard to section II.C.6.g. of this final rule with
performance period. We believe it is the application of certain MIPS policies comment period for further discussion
critical for virtual groups to be assessed to MIPS eligible clinicians in MIPS regarding the waiver.
and scored at the virtual group level for APMs (81 FR 77246 through 77269). In The following is a summary of the
all performance categories, as it the CY 2018 Quality Payment Program public comments received regarding our
eliminates the burden of virtual group proposed rule, we reiterated those proposals.
components having to report as a virtual concerns and proposed additional
Comment: Many commenters
group and separately outside of a virtual policies for the APM scoring standard
supported our proposals regarding the
group. Additionally, we believe that the (82 FR 30080 through 30091). We
assessment and scoring of virtual group
assessment and scoring at the virtual believe it is important to consistently
group level provides for a performance and the application of the
apply the APM scoring standard under
comprehensive measurement of MIPS payment adjustment to MIPS
MIPS for eligible clinicians participating
performance, shared responsibility, and eligible clinicians based on the virtual
in MIPS APMs in order to avoid
an opportunity to effectively and potential misalignments between the groups final score.
efficiently coordinate resources to also evaluation of performance under the Response: We appreciate the support
achieve performance under the terms of the MIPS APM and evaluation from the commenters.
improvement activities and the of performance on measures and Comment: One commenter supported
advancing care information performance activities under MIPS, and to preserve our proposal to assess and score virtual
categories. Therefore, we proposed at the integrity of the initiatives we are groups at the virtual group level and
414.1315(d)(4) that virtual groups testing. Therefore, we believe it is indicated that such an approach would
would be assessed and scored across all necessary to waive the requirement to provide comprehensive measurement,
four MIPS performance categories at the only use the virtual group scores under shared responsibility and coordination
virtual group level for a performance section 1848(q)(5)(I)(i)(II) of the Act, and of resources, and reduce burden.
period for a year (82 FR 30033 through instead to apply the score under the Another commenter expressed support
30034). APM scoring standard for eligible for requiring the aggregation of data
In the CY 2017 Quality Payment clinicians in virtual groups who are also across the TINs within a virtual group,
Program final rule (81 FR 77319 through in an APM Entity participating in an including the performance data of APM
77329), we established the MIPS final APM. participants, to assess the performance
score methodology at 414.1380, which Specifically, for participants in MIPS of a virtual group given that it would be
would apply to virtual groups. We refer APMs, we proposed to use our authority difficult for TINs to separate and
readers to sections II.C.4.h. and II.C.6.g. under section 1115A(d)(1) of the Act for exclude data for some NPIs. One
of this final rule with comment period MIPS APMs authorized under section commenter supported our proposal to
for scoring policies that would apply to 1115A of the Act, and under section utilize waiver authority, which allows
virtual groups. 1899(f) of the Act for the Shared Savings MIPS eligible clinicians within a virtual
As noted in section II.C.4.g. of this Program, to waive the requirement group to receive their MIPS payment
final rule with comment period, we under section 1848(q)(2)(5)(I)(i)(II) of the adjustment based on the virtual group
proposed to allow solo practitioners and Act that requires performance category score while allowing APM participants
groups with 10 or fewer eligible scores from virtual group reporting to be who are also a part of a virtual group to
clinicians that have elected to be part of used to generate the final score upon receive their MIPS payment adjustment
a virtual group to have their which the MIPS payment adjustment is based on their APM Entity score under
performance measured and aggregated based for all TIN/NPIs in the virtual the APM scoring standard.
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at the virtual group level across all four group. Instead, we would use the score Response: We appreciate the support
performance categories; however, we assigned to the MIPS eligible clinician from the commenters regarding our
would apply payment adjustments at based on the applicable APM Entity proposals.
the individual TIN/NPI level. Each TIN/ score to determine MIPS payment Comment: One commenter requested
NPI would receive a final score based on adjustments for all MIPS eligible clarification regarding whether or not
the virtual group performance, but the clinicians that are part of an APM Entity the MIPS payment adjustment would
payment adjustment would still be participating in a MIPS APM, in only apply to MIPS eligible clinicians
applied at the TIN/NPI level. We would accordance with 414.1370, instead of within a virtual group.

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Response: We note that each eligible attesting to only one to two performance categories at the virtual
clinician in a virtual group will receive improvement activities) in order to group level.
a virtual group score that is reflective of account for the short timeframe (a few Comment: One commenter suggested
the combined performance of a virtual months) TINs have to form and that CMS explore the development of a
group; however, only MIPS eligible implement virtual groups in preparation test to determine, in advance, if a virtual
clinicians will receive a MIPS payment for the CY 2018 performance period. group would have sufficient numbers
adjustment based on the virtual group Response: We appreciate the for valid measurement.
final score. In the case of an eligible recommendations from commenters. We Response: We interpret the
clinician participating in both a virtual believe that the ability for solo commenters reference to sufficient
group and an Advanced APM who has practitioners and groups to form and/or numbers for valid measurement to
achieved QP status, such eligible join virtual groups is an advantage and mean sufficient numerator and
clinician will be assessed under MIPS as provides flexibility. We note that virtual denominator data to enable the data to
part of the virtual group, but will still groups are generally able to take accurately reflect the virtual groups
be excluded from the MIPS payment advantage and benefit from all scoring performance on specific measures and
adjustment as a result of his or her QP incentives and bonuses that are activities. As virtual groups are
status. Conversely, in the case of an currently provided under MIPS. We will implemented, we will take this
eligible clinician participating in both a take into consideration the development recommendation into consideration.
virtual group and an Advanced APM of additional incentives, and any Comment: One commenter expressed
who has achieved Partial QP status, it is changes would be proposed in future concern that virtual groups would have
recognized that such eligible clinician rulemaking. the ability to skew benchmark scoring
would be excluded from the MIPS Comment: One commenter requested standards to the disadvantage of MIPS
payment adjustment unless such that CMS consider scoring virtual eligible clinicians who choose not to
eligible clinician elects to report under groups by weighting each individual participate in MIPS as part of a virtual
MIPS. We note that affirmatively group category score by the number of group.
clinicians. The commenter indicated Response: We disagree with the
agreeing to participate in MIPS as part
that the requirement to consolidate commenter and do not believe that
of a virtual group prior to the start of the
scoring for each performance category virtual groups would skew benchmark
applicable performance period would scoring standards to the disadvantage of
constitute an explicit election to report would limit the ability of TINs to take
advantage of the virtual group option, MIPS eligible clinicians participating in
under MIPS. Thus, eligible clinicians MIPS at the individual or group level as
who participate in a virtual group and particularly with regard to the
advancing care information performance a result of how benchmarks are
achieve Partial QP status would remain calculated, which is based on the
category, where the use of different EHR
subject to the MIPS payment adjustment composite of available data for all MIPS
vendors may make finding viable
due to their election to report under eligible clinicians. MIPS eligible
partners difficult and preclude easy
MIPS. New Medicare-enrolled eligible clinicians that are participating in MIPS
reporting. Another commenter indicated
clinicians and clinician types not as part of a virtual group would already
that our proposal to require virtual
included in the definition of a MIPS be eligible and able to participate in
groups to be scored across all
eligible clinician who are associated MIPS at the individual or group level;
performance categories may cause
with a TIN that is part of a virtual group therefore, the benchmark scoring
unintended consequences, such as
would receive a virtual group score, but standards would not be skewed
virtual groups being dissuaded from
would not receive a MIPS payment regardless of such MIPS eligible
admitting TINs that do have EHR
adjustment. MIPS eligible clinicians technology certified to the 2014 Edition clinicians participating in MIPS at the
who are participants in both a virtual in order for virtual groups advancing individual, group, or virtual group level.
group and a MIPS APM will be assessed care information performance category Also, we believe that solo practitioners
under MIPS as part of the virtual group scores not to be impacted. and groups with 10 or fewer eligible
and under the APM scoring standard as Response: We believe it is important clinicians that form virtual groups
part of an APM Entity group, but will for TINs participating in MIPS as part of would increase their performance by
receive their payment adjustment based a virtual group to be assessed and joining together.
only on the APM Entity score. scored at the virtual group level across Comment: One commenter urged
Comment: In order to increase virtual each performance category. We believe CMS to address risk adjustment
group participation and incentivize solo it provides continuity in assessment and mechanisms for virtual groups and
practitioners and groups (including allows virtual groups to share and develop methodologies to account for
rural and small practices) to form virtual coordinate resources pertaining to each the unique nature of virtual groups and
groups and move toward joint performance category. We recognize that noted that appropriate risk adjustment
accountability, many commenters there may be challenges pertaining to is critical for virtual groups because of
recommended that CMS provide bonus aligning EHR technology and the ways the heterogeneous make-up of virtual
points to TINs that elect to form virtual in which EHR technology captures data, groups (for example, geographic and
groups given that virtual groups would but believe that virtual groups have the specialty diversity).
face administrative and operational opportunity to coordinate and identify Response: We appreciate the
challenges, such as identifying reliable means to align elements of EHR recommendation from the commenter.
partners, aggregating and sharing data, technology that would benefit the Under the Improving Medicare Post-
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and coordinating workflow across virtual group. In order for virtual groups Acute Transformation (IMPACT) Act of
multiple TINs and NPIs. One to accurately have their performance 2014, the Office of the Assistant
commenter recommended that CMS assessed and scored as a collective Secretary for Planning and Evaluation
consider granting virtual groups (of any entity and identify areas to improve care (ASPE) has been conducting studies on
size) special reporting and/or scoring coordination, quality of care, and health the issue of risk adjustment for
accommodations similar to the outcomes, we believe that each eligible sociodemographic factors on quality
previously finalized and proposed clinician in a virtual group should be measures and cost, as well as other
policies for small practices (for example, assessed and scored across all four strategies for including social

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determinants of health status evaluation measures denominator criteria, then cumulatively aggregated across the
in CMS programs. We will closely regardless of payer for the performance virtual group. A virtual group would
examine the ASPE studies when they period. We expect to receive quality need to meet the beneficiary sampling
are available and incorporate findings as data for both Medicare and non- threshold cumulatively as a virtual
feasible and appropriate through future Medicare patients under these group.
rulemaking. Also, we will monitor submission mechanisms. Virtual groups In regard to performance under the
outcomes of beneficiaries with social submitting quality measures data using improvement activities performance
risk factors, as well as the performance the CMS Web Interface or a CMS- category, we clarified in the CY 2017
of the MIPS eligible clinicians who care approved survey vendor to report the Quality Payment Program final rule (81
for them to assess for potential CAHPS for MIPS survey must meet the FR 77181) that if one MIPS eligible
unintended consequences such as data submission requirements on the clinician (NPI) in a group completed an
penalties for factors outside the control sample of the Medicare Part B patients improvement activity, the entire group
of clinicians. CMS provides. We note that the (TIN) would receive credit for that
Comment: One commenter requested measure reporting requirements activity. In addition, we specified that
clarification regarding how compliance applicable to groups are also generally all MIPS eligible clinicians reporting as
would be implemented for the quality applicable to virtual groups. However, a group would receive the same score
and improvement activities performance we note that the requirements for for the improvement activities
categories at the virtual group level and calculating measures and activities performance category if at least one
whether or not a virtual group would be when reporting via QCDRs, qualified clinician within the group is performing
able to achieve the highest possible registries, EHRs, and attestation differ in the activity for a continuous 90 days in
score for the improvement activities their application to virtual groups. the performance period. As discussed in
performance category if only one NPI Specifically, these requirements apply section II.C.4.d. of this final rule with
within the virtual group meets the cumulatively across all TINs in a virtual comment period, we are finalizing our
requirements regardless of the total group. Thus, virtual groups will proposal to generally apply our
number of NPIs participating in the aggregate data for each NPI under each previously finalized and proposed
virtual group. Also, the commenter TIN within the virtual group by adding group policies to virtual groups, unless
requested clarification regarding together the numerators and otherwise specified. Thus, if one MIPS
whether or not a virtual group would denominators and then cumulatively eligible clinician (NPI) in a virtual group
meet the requirements under the quality collate to report one measure ratio at the completed an improvement activity, the
performance category if the virtual virtual group level. Moreover, if each entire virtual group would receive credit
group included a TIN that reported a MIPS eligible clinician within a virtual for that activity and receive the same
specialty measures set that is not group faces a significant hardship or has score for the improvement activities
applicable to other eligible clinicians in EHR technology that has been performance category if at least one
the virtual group. decertified, the virtual group can apply
Response: As discussed in section clinician within the virtual group is
for an exception to have its advancing performing the activity for a minimum
II.C.4.d. of this final rule with comment
care information performance category of a continuous 90-day period in CY
period, we are generally applying our
reweighted. If such exception 2018. In order for virtual groups to
previously finalized and proposed
application is approved, the virtual achieve full credit under the
group policies to virtual groups, unless
groups advancing care information improvement activities performance
specified. Thus, in order for virtual
performance category is reweighted to category for the 2018 performance
groups to meet the requirements for the
zero percent and applied to the quality period, they would need to submit four
quality and improvement activities
performance categories, they would performance category increasing the medium-weighted or two high-weighted
need to meet the same requirements quality performance weight from 50 activities that were for a minimum of a
established for groups and meet virtual percent to 75 percent. continuous 90-day period in CY 2018.
group reporting requirements. Virtual Additionally, the data submission Virtual groups that are considered to be
groups will have their performance criteria applicable to groups are also non-patient facing or small practices, or
assessed and scored for the quality and generally applicable to virtual groups. designated as rural or HPSA practices
improvement activities performance However, we note that data will receive full credit by submitting
categories based submitting the completeness and sampling one high-weighted improvement
minimum number of measures and requirements for the CMS Web Interface activity or two medium-weighted
activities. Generally, virtual groups and CAHPS for MIPS survey differ in improvement activities that were
reporting quality measures are required their application to virtual groups. conducted for a minimum of a
to select at least 6 measures, one of Specifically, data completeness for continuous 90-day period in CY 2018.
which must be an outcome measure, or virtual groups applies cumulatively In regard to compliance with quality
if an outcome measure is not available across all TINs in a virtual group. Thus, and improvement activities performance
a high priority measure to collectively we note that there may be a case when category requirements, virtual groups
report for the performance period of CY a virtual group has one TIN that falls would meet the same performance
2018. Virtual groups are encouraged to below the 60 percent data completeness category requirements applicable to
select the quality measures that are most threshold, which is an acceptable case groups. In section II.C.4.g. of this final
appropriate to the TINs and NPIs within as long as the virtual group rule with comment period, we outline
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their virtual group and patient cumulatively exceeds such threshold. In virtual group reporting requirements.
population. regard to the CMS Web Interface and Virtual groups are required to adhere to
For the 2018 performance period, CAHPS for MIPS survey, sampling the requirements established for each
virtual groups submitting data on requirements pertain to Medicare Part B performance category. Performance data
quality measures using QCDRs, patients with respect to all TINs in a submitted to CMS on behalf of virtual
qualified registries, or via EHR must virtual group, where the sampling groups must be meet form and manner
report on at least 60 percent of the methodology would be conducted for requirements for each submission
virtual groups patients that meet the each TIN within the virtual group and mechanism.

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Final Action: After consideration of performance period. In this final rule CMS allowing clinicians to choose the
the public comments received, we are with comment period, we are finalizing length of their performance period. One
finalizing the following proposals. Solo three policies (small practice size commenter recommended that CMS
practitioners and groups with 10 or determination, non-patient facing provide bonus points to clinicians who
fewer eligible clinicians that have determination, and low-volume report for a performance period that is
elected to be part of a virtual group will threshold determination) that utilize a longer than 90 days. A few commenters
have their performance measured and 30-day claims run out. We refer readers recommended that CMS analyze the
aggregated at the virtual group level to sections II.C.l.c., II.C.l.e., and II.C.2.c. quality and cost performance data to
across all four performance categories. of this final rule with comment period determine the appropriate length of the
We will apply payment adjustments at for details on these three policies. performance period, taking into
the individual TIN/NPI level. Each TIN/ Lastly, we finalized that individual consideration whether there are any
NPI will receive a final score based on MIPS eligible clinicians or groups who unintended consequences for practices
the virtual group performance, but the report less than 12 months of data (due of a particular size or specialty. One
payment adjustment would still be to family leave, etc.) are required to commenter suggested that CMS work
applied at the TIN/NPI level. We will report all performance data available with physicians to develop options and
assign the virtual group score to all TIN/ from the applicable performance period a specific plan to provide
NPIs billing under a TIN in the virtual (for example, CY 2018 or a minimum of accommodations where possible, such
group during the performance period. a continuous 90-day period within CY as providing clinicians multiple
For participants in MIPS APMs, we 2018). different performance periods to choose
will use our authority under section We proposed at 414.1320(c)(1) that from. A few commenters noted that a
1115A(d)(1) for MIPS APM authorized for purposes of the 2021 MIPS payment 90-day performance period may
under section 1115A of the Act, and year and future years, the performance eliminate issues for clinicians that
under section 1899(f) for the Shared period for the quality and cost either switch or update their EHR
Savings Program, to waive the performance categories would be the system during the performance period.
requirement under section 1848 full calendar year (January 1 through Furthermore, a few commenters noted
(q)(2)(5)(I)(i)(II) of the Act that requires December 31) that occurs 2 years prior that since the QCDR self-nominations
performance category scores from to the applicable payment year. For are not due until November 1, 2017,
virtual group reporting to be used to example, for the 2021 MIPS payment CMS would need to review and approve
generate the final score upon which the year, the performance period would be QCDR measures within less than 2
MIPS payment adjustment is based for CY 2019 (January 1, 2019 through months, for clinicians to have QCDR
all TIN/NPIs in the virtual group. We December 31, 2019), and for the 2022 measures to report at the start of the CY
will use the score assigned to the MIPS MIPS payment year, the performance 2018 performance period. One
eligible clinician based on the period would be CY 2020 (January 1, commenter noted that a 90-day
applicable APM Entity score to 2020 through December 31, 2020). performance period is preferable as
determine MIPS payment adjustments We proposed at 414.1320(d)(1) that
clinicians will need time to update their
for all MIPS eligible clinicians that are for purposes of the 2021 MIPS payment
systems and train staff after QCDR
part of an APM Entity participating in year, the performance period for the
measures have been approved.
a MIPS APM, in accordance with improvement activities and advancing
414.1370, instead of determining MIPS care information performance categories Response: We understand the
payment adjustments for these MIPS would be a minimum of a continuous commenters concerns. However, we
eligible clinicians using the final score 90-day period within CY 2019, up to believe that it would not be in the best
of their virtual group. and including the full CY 2019 (January interest of MIPS eligible clinicians to
1, 2019 through December 31, 2019). have less than a full calendar year
5. MIPS Performance Period The following is a summary of the performance period for the quality and
In the CY 2017 Quality Payment public comments received on the MIPS cost performance categories beginning
Program final rule (81 FR 77085), we Performance Period proposals and our with the 2021 MIPS payment year, as
finalized at 414.1320(b)(1) that for responses: we previously finalized at
purposes of the 2020 MIPS payment Comment: Many commenters did not 414.1320(b)(1) a full calendar year
year, the performance period for the support our proposal that beginning performance period for the quality and
quality and cost performance categories with the 2021 MIPS payment year, the cost performance categories for the 2020
is CY 2018 (January 1, 2018 through performance period for the quality and MIPS payment year, which will occur
December 31, 2018). We finalized at cost performance categories would be during CY 2018. By finalizing a full
414.1320(b)(2) that for purposes of the the full calendar year that occurs 2 years calendar year performance period for
2020 MIPS payment year, the prior to the applicable payment year. the quality and cost performance
performance period for the The commenters believed that MIPS categories for the 2021 MIPS payment
improvement activities and advancing eligible clinicians are not prepared to year, we are maintaining consistency
care information performance categories move from pick your pace flexibility with the performance period for the
is a minimum of a continuous 90-day to a full calendar year performance 2020 MIPS payment year. We believe
period within CY 2018, up to and period and that the proposal would this will be less burdensome and
including the full CY 2018 (January 1, create significant administrative burden confusing for MIPS eligible clinicians.
2018, through December 31, 2018). We and confusion for MIPS eligible We also would like to note that a longer
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did not propose any changes to these clinicians. A few commenters noted that performance period for the quality and
policies. a full calendar year of data does not cost performance categories will likely
We also finalized at 414.1325(f)(2) necessarily improve the validity of the include more patient encounters, which
that for Medicare Part B claims, data data. Many commenters recommended will increase the denominator of the
must be submitted on claims with dates that CMS continue pick your pace quality and cost measures. Statistically,
of service during the performance flexibility with respect to the larger sample sizes provide more
period that must be processed no later performance period, while several accurate and actionable information.
than 60 days following the close of the commenters expressed an interest in Additionally, the longer performance

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period (a year) is consistent with how payment year. The commenters noted Response: We understand the
many of the measures used in our that MIPS eligible clinicians are not commenters concerns that the proposed
program were designed to be reported prepared to move from pick your pace performance periods for quality and cost
and performed, such as Quality #303 flexibility to a full calendar year would not be consistent with the
(Cataracts: Improvement in Patients performance period and that this policy improvement activities and advancing
Visual Function within 90 Days will create significant administrative care information performance
Following Cataract Surgery) and Quality burden and confusion for MIPS eligible categories. For the improvement
#304 (Cataracts: Patient Satisfaction clinicians. activities performance category, a
within 90 Days Following Cataract Response: We understand the minimum of a continuous 90-day
Surgery). Finally, some of the measures commenters concerns in regards to the performance period provides MIPS
do not allow for a 90-day performance full calendar year MIPS performance eligible clinicians more flexibility as
period (such as those looking at period for the quality performance some improvement activities may be
complications after certain surgeries or category for the 2020 MIPS payment ongoing, while others may be episodic.
improvement in certain conditions after year. We would like to note that the For the advancing care information
treatment). In regards to the MIPS performance period for the 2020 performance category, a minimum of a
recommendation of providing bonus MIPS payment year was finalized in the continuous 90-day period performance
points to MIPS eligible clinicians that CY 2017 Quality Payment Program final period provides MIPS eligible clinicians
report for a performance period longer rule, and we made no new proposals for more flexibility and time to adopt and
than 90 days, we believe a more the MIPS performance period for the implement 2015 Edition CEHRT. As for
appropriate incentive is for MIPS 2020 MIPS payment year. Therefore, we the quality and cost performance
eligible clinicians to perform on a full are unable to modify the MIPS categories, we believe that a full
year so that they have the ability to performance period for the quality calendar year performance period is
improve their performance due to performance category for the 2020 MIPS most appropriate. Additionally,
having a larger sample size, etc. We also payment year. submitting only 90 days of performance
understand the commenters preference Comment: Several commenters data may create challenges for specific
of a 90-day performance period, so that supported the proposal to increase the measures. Finally, with respect to the
there is adequate time to update systems performance period for the 2021 MIPS cost performance category, we would
and train staff. We agree that adequate payment year and future payment years like to note that no data submission is
time is needed to update systems, to 12 months occurring 2 years prior required, as this performance category is
workflows and train staff. However, we because the longer performance period calculated utilizing Part B claim data.
note that the quality measures are provides a more accurate picture of Comment: Many commenters
eligible clinicians performance. A few supported the proposed 90-day
finalized as part of this final rule, and
commenters noted that their support performance period for the
the specifications are published on our
was contingent on CMS approving 2018 improvement activities and advancing
Web site by no later than December 31
QCDR measure specifications by care information performance
prior to the performance period. While
December 1, 2017. One commenter categories. A few commenters requested
we strongly encourage all clinicians to
noted that a 90-day performance period that CMS adopt a 90-day performance
review the current performance periods
is insufficient to thoroughly assess period for the improvement activities
measure specifications, we note that the
performance. One commenter noted that and advancing care information
overwhelming majority of MIPS quality
the full year will ensure continuity in performance categories for the 2022
measures are maintained year over year
the quality of care delivered to MIPS payment year and future years.
with only minor code set updates. beneficiaries. One commenter noted that Response: We thank the commenters
Further, for quality, we have a 60 a TIN participating in Track 1 of the for their support and will consider the
percent data completeness threshold, Shared Savings Program is commenters recommendation for future
which provides a buffer for clinicians if automatically required to report for the rulemaking.
they are not able to implement their full year, so requiring all MIPS eligible Comment: A few commenters did not
selected measures immediately at the clinicians to participate for a full year support the length of time between the
start of the performance period. Finally, would be fairer now that scores are proposed performance period and the
we would like to clarify that many reflected on Physician Compare. applicable payment year because the
registries, QCDRs, and EHRs have the Response: We thank the commenters commenters believed it would not allow
ability to accept historical data so that for their support. We would also like to practices time to make necessary
once the EHR system is switched or note that in the CY 2017 Quality adjustments before the next
updated, the MIPS eligible clinician can Payment Program final rule (81 FR performance period begins. One
report their information. With regard to 77158), we stated that we would post commenter recommended that, as the
the suggestion that we work with the approved QCDR measures through program matures, one consideration for
physicians to develop options and a the qualified posting by no later than shortening this timeframe could be a
specific plan to provide January 1, 2018. quarterly rolling annual performance
accommodations where possible, such Comment: A few commenters did not period with a three- to 6-month
as providing clinicians multiple support the proposed performance validation period prior to any payment
different performance periods to choose periods because the quality and cost adjustment. Another commenter
from, we will consider this suggestion performance categories would not be recommended that we consider
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for future rulemaking as necessary. aligned with the improvement activities staggered performance periods; for
Comment: While we did not propose and advancing care information example payment adjustments for 2021,
any changes to the previously finalized performance categories. The would ideally be based on a
performance periods for the 2020 MIPS commenters believed it would be performance period running from July 1,
payment year, many commenters did confusing to clinicians. One commenter 2019 through June 30, 2020.
not support a full calendar year recommended that all performance Response: We understand the
performance period for the quality categories have a 12-month performance commenters concerns regarding the
performance category for the 2020 MIPS period. length of time between the proposed

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performance period and the applicable Comment: One commenter 6. MIPS Performance Category Measures
payment year and appreciate the encouraged CMS to implement the and Activities
commenters suggestions for shortening MIPS program as soon as possible. This a. Performance Category Measures and
this timeframe. While a shortened commenter noted that a transition Reporting
timeframe between performance period period could discourage eligible
and payment year may be desirable, clinicians from participating in the (1) Submission Mechanisms
there are operational challenges with program. We finalized in the CY 2017 Quality
this approach that we do not anticipate Payment Program final rule (81 FR
can be resolved in the near future. Response: We appreciate the
commenters recommendation to 77094) at 414.1325(a) that individual
Specifically, we need to allow time for MIPS eligible clinicians and groups
the post submission processes of implement the MIPS program as soon as
must submit measures and activities, as
calculating MIPS eligible clinicians possible; however, we disagree that a
applicable, for the quality, improvement
final scores, establishing budget transition period will discourage
activities, and advancing care
neutrality, issuing the payment participation. We believe that a information performance categories. For
adjustment factors, and allowing for a transition period will reduce barriers the cost performance category, we
targeted review period to occur prior to from participation that existed in the finalized that each individual MIPS
the application of the MIPS payment legacy programs. eligible clinicians and groups cost
adjustment to MIPS eligible clinicians Final Action: After consideration of performance would be calculated using
claims. However, we are continuing to the public comments, we are finalizing administrative claims data. As a result,
look for opportunities to shorten the at 414.1320(c)(1) that for purposes of individual MIPS eligible clinicians and
timeframe between the end of the the 2021 MIPS payment year, the groups are not required to submit any
performance period and when payment performance period for the quality and additional information for the cost
adjustments are applied. cost performance categories is CY 2019 performance category. We finalized in
Comment: One commenter (January 1, 2019 through December 31, the CY 2017 Quality Payment Program
recommended a 2-year performance 2019). We are not finalizing the final rule (81 FR 77094 through 77095)
period for clinicians who have patient proposed performance period for the multiple data submission mechanisms
volume insufficient for statistical for MIPS, which provide individual
quality and cost performance categories
analysis so that the clinician has a MIPS eligible clinicians and groups
for purposes of the 2022 MIPS payment
sufficient sample size to analyze. with the flexibility to submit their MIPS
year and future years. We are also
Response: We thank the commenter measures and activities in a manner that
redesignating proposed 414.1320(d)(1)
for their suggestion and will consider it best accommodates the characteristics of
and finalizing at 414.1320(c)(2) that for
for future rulemaking. We would like to their practice, as indicated in Tables 2
note that in this final rule with purposes of the 2021 MIPS payment and 3. Table 2 summarizes the data
comment period, we are only finalizing year, the performance period for the submission mechanisms for individual
the performance period for the 2021 advancing care information and MIPS eligible clinicians that we
MIPS payment year, not future years, so improvement activities performance finalized at 414.1325(b) and (e). Table
that we can continue to monitor and categories is a minimum of a continuous 3 summarizes the data submission
assess whether changes to the 90-day period within CY 2019, up to mechanisms for groups that are not
performance period through future and including the full CY 2019 (January reporting through an APM that we
rulemaking would be beneficial. 1, 2019 through December 31, 2019). finalized at 414.1325(c) and (e).
TABLE 2DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING INDIVIDUALLY
[TIN/NPI]

Performance category/submission Individual reporting data submission mechanisms


combinations accepted

Quality ................................................................. Claims.


QCDR.
Qualified registry.
EHR.
Cost ..................................................................... Administrative claims.1
Advancing Care Information ................................ Attestation.
QCDR.
Qualified registry.
EHR.
Improvement Activities ........................................ Attestation.
QCDR.
Qualified registry.
EHR.

TABLE 3DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING AS GROUPS
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[TIN]

Performance category/submission Group reporting data submission mechanisms


combinations accepted

Quality ................................................................. QCDR.


Qualified registry.
EHR.

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TABLE 3DATA SUBMISSION MECHANISMS FOR MIPS ELIGIBLE CLINICIANS REPORTING AS GROUPSContinued
[TIN]

Performance category/submission Group reporting data submission mechanisms


combinations accepted

CMS Web Interface (groups of 25 or more).


CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with an-
other data submission mechanism).
and
Administrative claims (for all-cause hospital readmission measure; no submission required).
Cost ..................................................................... Administrative claims.1
Advancing Care Information ................................ Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or more).
Improvement Activities ........................................ Attestation.
QCDR.
Qualified registry.
EHR.
CMS Web Interface (groups of 25 or more).

We finalized at 414.1325(d) that mechanisms. We would only count the As discussed in section II.C.4 of this
individual MIPS eligible clinicians and submission that gives the clinician the final rule with comment period, we
groups may elect to submit information higher score, thereby avoiding the proposed to generally apply our
via multiple mechanisms; however, they double count. We refer readers to previously finalized and proposed
must use the same identifier for all section II.C.7.a.(2) of this final rule with group policies to virtual groups. With
performance categories, and they may comment period, which further outlines respect to data submission mechanisms,
only use one submission mechanism per how we proposed to score measures and we proposed that virtual groups would
performance category. activities regardless of submission be able to use a different submission
We proposed to revise 414.1325(d) mechanism. mechanism for each performance
for purposes of the 2020 MIPS payment We believe that this flexible approach category, and would be able to utilize
year and future years, beginning with would help individual MIPS eligible multiple submission mechanisms for
performance periods occurring in 2018, clinicians and groups with reporting, as the quality performance category,
to allow individual MIPS eligible it provides more options for the beginning with performance periods
clinicians and groups to submit data on submission of data for the applicable occurring in 2018 (82 FR 30036).
measures and activities, as applicable performance categories. We believe that However, virtual groups would be
and available, via multiple data by providing this flexibility, we would required to utilize the same submission
submission mechanisms for a single be allowing MIPS eligible clinicians to mechanism for the improvement
performance category (specifically, the choose the measures and activities that activities and the advancing care
quality, improvement activities, or are most meaningful to them, regardless information performance categories.
advancing care information performance of the submission mechanism. We are
aware that this proposal for increased For those MIPS eligible clinicians
category) (82 FR 30035). Under this
flexibility in data submission participating in a MIPS APM, who are
proposal, individual MIPS eligible
mechanisms may increase complexity on an APM Participant List on at least
clinicians and groups that have fewer
and in some instances necessitate one of the three snapshot dates as
than the required number of measures
additional costs for clinicians, as they finalized in the CY 2017 Quality
and activities applicable and available
may need to establish relationships with Payment Program Final Rule (81 FR
under one submission mechanism could
submit data on additional measures and additional data submission mechanism 77444 through 77445), or for MIPS
activities via one or more additional vendors in order to report additional eligible clinicians participating in a full
submission mechanisms, as necessary, measures and/or activities for any given TIN MIPS APM, who are on an APM
to receive a potential maximum number performance category. We clarified that Participant List on at least one of the
of points under a performance category. the requirements for the performance four snapshot dates as discussed in
If an individual MIPS eligible categories remain the same, regardless section II.C.6.g.(2) of this final rule with
clinician or group submits the same of the number of submission comment period, the APM scoring
measure through two different mechanisms used. It is also important to standard applies. We refer readers to
mechanisms, each submission would be note that for the improvement activities 414.1370 and the CY 2017 Quality
calculated and scored separately. We do and advancing care information Payment Program final rule (81 FR
not have the ability to aggregate data on performance categories, that using 77246), which describes how MIPS
the same measure across submission multiple data submission mechanisms eligible clinicians participating in APM
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may limit our ability to provide real- entities submit data to MIPS in the form
1 Requires no separate data submission to CMS: time feedback. While we strive to and manner required, including
Measures are calculated based on data available provide flexibility to individual MIPS separate approaches to the quality and
from MIPS eligible clinicians billings on Medicare eligible clinicians and groups, we noted cost performance categories applicable
Part B claims. Note: Claims differ from that our goal within the MIPS program to MIPS APMs. We did not propose any
administrative claims as they require MIPS eligible
clinicians to append certain billing codes to
is to minimize complexity and changes to how APM entities in MIPS
denominator eligible claims to indicate the required administrative burden to individual APMs and their participating MIPS
quality action or exclusion occurred. MIPS eligible clinicians and groups. eligible clinicians submit data to MIPS.

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The following is a summary of the performance period, we will apply our performance periods beginning in 2019,
public comments received on the validation process to determine if other if a MIPS eligible clinician or group
Performance Category Measures and measures are available and applicable reports for the quality performance
Reporting: Submission Mechanisms only with respect to the data submission category by using multiple instances of
proposal and our responses: mechanism(s) that a MIPS eligible the same data submission mechanism
Comment: Many commenters clinician utilizes for the quality (for example, multiple EHRs) then all
supported the proposal to allow MIPS performance category for a performance the submissions would be scored, and
eligible clinicians and groups to submit period. With regard to a specialty the 6 quality measures with the highest
measures and activities via multiple measure set, specialists who report on a performance (that is, the greatest
submission mechanisms. Several speciality measure set are only required number of measure achievement points)
commenters noted it will help ease to report on the measures within that would be utilized for the quality
reporting and administrative burden. set, even if it is less than the required performance category score. As noted
Several commenters also noted it will 6 measures. If the specialty set includes above, if an individual MIPS eligible
provide greater flexibility, including measures that are available through clinician or group submits the same
increasing the number of measures multiple submission mechanisms, then measure through two different
available. Several commenters stated it through this policy, beginning with the mechanisms, each submission would be
will allow clinicians to report the 2019 performance period, the option to calculated and scored separately. We do
measures that are most meaningful and report additional measures would be not have the ability to aggregate data on
applicable to them. Several commenters available for those that have applicable the same measure across multiple
also stated it will help MIPS eligible measures and/or activities available to submission mechanisms. We would
clinicians and groups successfully them, which may potentially increase only count the submission that gives the
report required measures and meet their score, but they are not required to clinician the higher score, thereby
MIPS reporting requirements. A few utilize multiple submission methods to avoiding the double count. For example,
commenters specifically supported the meet the 6 measure requirement. In if a MIPS eligible clinician submits
policy to allow reporting of quality addition, for MIPS eligible clinicians performance data for Quality Measure
measures across multiple data reporting on a specialty measure set via 236, Controlling High Blood Pressure,
submission mechanisms because 6 claims or registry, we will apply our using a registry and also through an
clinically-applicable quality measures validation process to determine if other EHR, these two submissions would be
may not always be available using one measures are available and applicable scored separately, and we would apply
submission mechanism; it will provide within the specialty measure set only the submission with the higher score
clinicians who belong to multi-specialty with respect to the data submission towards the quality performance score.
groups more ease in reporting quality mechanism(s) that a MIPS eligible We would not aggregate the score of the
measures they may be already reporting clinician utilizes for the quality registry and EHR submission of the
to qualified vendors, versus forcing performance category for a performance same measure. This approach decreases
different specialties to find a common period. the likelihood of cumulative
reporting platform that causes much Comment: A few commenters stated overcounting in the event that the
more administrative, and often financial this proposal will allow MIPS eligible submissions may have time or patient
burden; it will allow greater flexibility clinicians to determine which method is overlaps that may not be readily
in measure selection and will most appropriate for the different MIPS identifiable.
particularly benefit specialists who may categories. Several commenters noted it Comment: One commenter supported
want to report one or 2 eCQMs but will will encourage MIPS participation. that virtual groups would be able to use
need to use a registry to report the rest Many commenters stated it will multiple submission mechanisms for
of their measure set; and it is especially encourage the reporting of measures quality reporting but would have to use
helpful for those who want to report via through new submission methods such the same submission mechanism for the
EHR to the extent possible even though as QCDRs and EHRs. A few commenters improvement activities and advancing
not all measures can be submitted via stated it will reduce burden on care information performance
that mechanism. One commenter asked clinicians and EHR vendors by allowing categories. A few commenters suggested
if specialists who would have used a large groups that report under different that both groups and virtual groups have
specialty measure set would be required EHRs to report using multiple EHRs. the same submission requirements.
to use multiple submission methods to Response: In the CY 2017 Quality Another commenter suggested that we
meet the 6-measure requirement. Payment Program final rule, we reconsider multiple submission
Response: We appreciate the finalized that for the quality mechanisms due to the complexity it
commenters support for our proposal. performance category, an individual will place on clinicians.
Due to operational feasibility concerns, MIPS eligible clinician or group that Response: We are not finalizing our
we are not finalizing this proposal submits data on quality measures via proposal that virtual groups would be
beginning with the CY 2018 EHR, QCDR, qualified registry, claims, required to utilize the same submission
performance period as proposed, but or a CMS-approved survey vendor for mechanism for the improvement
instead beginning with the CY 2019 the CAHPS for MIPS survey will be activities and the advancing care
performance period. Moreover, we are assigned measure achievement points information performance categories
not requiring that MIPS individual for 6 measures (1 outcome, or if an because we believe that virtual groups
clinicians and groups submit via outcome measure is not available, should have the same reporting
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additional submission mechanisms; another high priority measure and the capabilities as groups. Thus, groups and
however, through this proposal the next 5 highest scoring measures) as virtual groups have the same
option would be available for those that available and applicable, and we will submission requirements, which for the
have applicable measures and/or receive applicable measure bonus points CY 2018 performance period, includes
activities available to them. As for all measures submitted that meet the the utilization of multiple submission
discussed in section II.C.7.a.(2)(e) of this bonus criteria (81 FR 77282 through mechanisms with the caveat that only
final rule with comment period, 77301). Consistent with this policy, we one submission mechanism must be
beginning with the CY 2019 would like to clarify that for used per performance category. Starting

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with the CY 2019 performance period, burdens with requiring clinicians to use That CMS eventually require a MIPS
groups and virtual groups will be able multiple submission mechanisms, if eligible clinician or group to submit all
to utilize multiple submission they have fewer than the required data on measures and activities across a
mechanisms for each performance number of measures and activities single data submission mechanism of
category. As noted above, due to applicable and available under one their choosing to ensure that reliable,
operational feasibility concerns, we are submission mechanism, as the trustworthy, comparative data can be
not finalizing this proposal beginning requirements for the performance extracted from the MIPS eligible
with the CY 2018 performance period as categories remain the same regardless of clinician and/or groups MIPS
proposed, but instead beginning with the number of submission mechanisms performance information and to
the CY 2019 performance period. used. A commenter expressed concern alleviate the resource intensity
Comment: A few commenters stated with making multiple submissions part associated with retaining all data across
this proposal would help clinicians and of the measure validation process for the the multiple submission mechanisms
groups receive the maximum number of review of whether 6 measures are for auditing purposes; and that claims-
points available. One commenter noted available for reporting. only reporting for the quality
it will ease the path for small and rural Response: We appreciate the performance category be phased-out due
practice clinicians to participate in commenters support for our proposal. to difficulty with clinically abstracting
MIPS. One commenter stated it will Due to operational feasibility concerns, meaningful quality data.
support reporting the highest quality we are not finalizing this proposal Response: We thank the commenter
data available. One commenter noted it beginning with the CY 2018 for their recommendations regarding
may allow clinicians to complete more performance period as proposed, but using a single data submission
activities. One commenter noted it will instead beginning with the CY 2019 mechanism and phasing out claims-only
provide EHR and registry vendors performance period. Moreover, we are reporting for the quality performance
flexibility in submitting data on behalf not requiring that MIPS individual category, and will take their
of their customers. One commenter clinicians and groups submit via recommendations into consideration for
stated that while it may add some additional submission mechanisms; future rulemaking. We refer readers to
burdens to reporting quality measures however, through this proposal the section II.C.9.c of this final rule with
because MIPS eligible clinicians will be option would be available for those that comment period for a discussion of our
required to report on 6 quality measures have applicable measures and/or data validation and auditing policies.
instead of only the number available via activities available to them. As Comment: Commenters requested that
a given submission mechanism, they discussed in section II.C.7.a.(2)(e) of this CMS continue to look for ways to
stated that they believe it will ultimately final rule with comment period, increase flexibility in the Quality
drive adoption of more robust measures beginning with the CY 2019 Payment Program and believed the best
based on clinical data and outcomes. performance period, we will apply our way to ensure participating clinicians
Response: We note that under this validation process to determine if other can meet the requirements of each
policy, individual MIPS eligible measures are available and applicable performance category is to increase the
clinicians and groups are not required only with respect to the data submission number of meaningful measures
to, but may use multiple data mechanism(s) that a MIPS eligible available. For clinicians who do not
submission mechanisms to report on six clinician utilizes for the quality want to manage multiple submission
quality measures in order to potentially performance category for a performance mechanisms an alternative solution
achieve the maximum score for the period. With regard to a specialty would be for each specialty within a
quality performance category beginning measure set, specialists who report on a group to create their own TINs and
with the 2019 performance period. speciality measure set are only required report as subgroups, because the
Individual MIPS eligible clinicians and to report on the measures within that commenter stated that allowing all
groups could report on additional set, even if it is less than the required MIPS eligible groups to report unique
measures and/or activities using 6 measures. If the specialty set includes sets of measures via a single mechanism
multiple data submission mechanisms measures that are available through or multiple mechanisms promotes the
for the Quality, Advancing Care multiple submission mechanisms, then ability for all clinicians to have a
Information, and Improvement through this policy, beginning with the meaningful impact on overall MIPS
Activities performance categories 2019 performance period, the option to performance, although the commenter
should applicable measures and/or report additional measures would be recognized that this subgroup approach
activities be available to them. We agree available for those that have applicable could create challenges with the current
that this policy provides small and rural measures and/or activities available to MIPS group scoring methodology.
practice clinicians with additional them, which may potentially increase Response: We agree that reporting on
flexibility to participate in MIPS by not their score, but they are not required to quality measures should be meaningful
limiting them to the use of one utilize multiple submission methods to for clinicians, and note that measures
submission mechanism per performance meet the 6 measure requirement. In are taken into consideration on an
category. We believe that MIPS eligible addition, for MIPS eligible clinicians annual basis prior to rule-making and
clinicians and groups should select and reporting on a specialty measure set via we encourage stakeholders to
report on measures that provide claims or registry, we will apply our communicate their concerns regarding
meaningful measurement within the validation process to determine if other gaps in measure development to
scope of their practice that should measures are available and applicable measure stewards. We thank
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include a focus on more outcomes-based within the specialty measure set only commenters for their suggestions
measurement. with respect to the data submission regarding an alternative approach to
Comment: One commenter who mechanism(s) that a MIPS eligible submission mechanisms. We would like
supported the proposal expressed clinician utilizes for the quality to clarify that each newly created TIN
concern that the flexibility may create performance category for a performance would be considered a new group, and
more complexity and confusion, as well period. as discussed in the CY 2018 Quality
as burden on CMS. Another commenter Comment: A few commenters offered Payment Program proposed rule (82 FR
stated that while there could be some additional recommendations including: 30027), we intend to explore the

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feasibility of establishing group-related track measures. One commenter asked the CY 2019 performance period, we
policies that would permit participation for clarification to distinguish between will apply our validation process to
in MIPS at a subgroup level through the scenarios where a clinician is determine if other measures are
future rulemaking. We refer readers required to submit under both EHR and available and applicable only with
section II.C.3. of this final rule with registry because their EHR is not respect to the data submission
comment period for additional certified for enough measures and when mechanism(s) that a MIPS eligible
information regarding group reporting. a clinician is required to submit under clinician utilizes for the quality
Comment: Commenters suggested that both EHR and registry because CMS has performance category for a performance
CMS ensure that entire specialty not created enough electronic measures period. With regard to a specialty
specific measure sets can be reported for the clinicians specialty. measure set, specialists who report on a
through a single submission mechanism Response: We appreciate the speciality measure set are only required
of their choice, specifically expressing suggestions, and will take them into to report on the measures within that
concern for the measures within the consideration for future rulemaking. As set, even if it is less than the required
radiation oncology subspecialty indicated in the CY 2017 Quality 6 measures. If the specialty set includes
measure set. Payment Program final rule (81 FR measures that are available through
Response: We would like to note that multiple submission mechanisms, then
77090), we intend to reduce the number
a majority of the measures in the through this policy, beginning with the
of claims-based measures in the future
specialty measure sets are available 2019 performance period, the option to
as more measures are available through
through registry reporting, and that report additional measures would be
health IT mechanisms that produce
specifically to the commenters concern, available for those that have applicable
valid measurement such as registries,
that all the measures within the measures and/or activities available to
QCDRs, and health IT vendors. We plan
radiation oncology subspecialty them, which may potentially increase
measure set are available through to continuously work with MIPS eligible
clinicians and other stakeholders to their score, but they are not required to
registry reporting. A majority of the utilize multiple submission methods to
quality measures in the MIPS program continue to improve the submission
mechanisms available for MIPS. We meet the 6 measure requirement. In
are not owned by CMS, but rather are addition, for MIPS eligible clinicians
developed and maintained by third agree that there is value to EHR based
reporting; however, we recognize that reporting on a specialty measure set via
party measure stewards. As a part of claims or registry, we will apply our
measure development and maintenance, there are relatively fewer measures
available via EHR reporting and we validation process to determine if other
measure stewards conduct feasibility measures are available and applicable
testing of adding a new submission generally want to retain solutions that
are low burden unless and until we within the specialty measure set only
mechanism as a reporting option for with respect to the data submission
their measure. We will share this identify viable alternatives. As indicated
in the quality measures appendices in mechanism(s) that a MIPS eligible
recommendation with the measure
this final rule with comment period, we clinician utilizes for the quality
stewards for future consideration.
are finalizing 54 out of the 275 quality performance category for a performance
Comment: One commenter suggested
that CMS retroactively provide similar measures available through EHR period.
flexibility for the CY 2017 MIPS reporting for the CY 2018 performance Comment: Several commenters
performance period. period. MIPS eligible clinicians should recommended that CMS make multiple
Response: For operational and evaluate the options available to them submission mechanisms optional only.
feasibility reasons, we believe that it and choose which available submission A few commenters expressed concern
would not be possible to retroactively mechanism and measures they believe that a requirement to report via multiple
allow MIPS individual eligible will provide meaningful measurement mechanisms to meet the required 6
clinicians and groups to submit data for their scope of practice. We intend to measures in the quality performance
through multiple submission provide stakeholders with additional category would increase burden on
mechanisms for the CY 2017 MIPS education with regards to the use of MIPS eligible clinicians and groups that
performance period. multiple submission mechanisms by the are unable to meet the minimum
Comment: Some commenters implementation of this policy for the CY requirement using one submission
suggested that CMS not overly rely on 2019 performance period. We plan to mechanism. A few commenters stated
claims-based measures to drive quality continuously work with MIPS eligible that MIPS eligible clinicians and groups
improvement and scoring in future clinicians and other stakeholders to should not be required to contract with
program years, that CMS develop a continue to improve the submission vendors and pay to report data on
transition plan toward only accepting mechanisms available for MIPS. It is not additional quality measures that are not
data from electronic systems that have our intent to provide larger practices an reportable through their preferred
demonstrated abilities to produce valid advantage over smaller practices, rather method or be penalized for failing to
measurement, such as those EHRs that our intention is to provide all MIPS report additional measures via a second
have achieved NCQA eMeasure eligible clinicians and groups the submission mechanism and that CMS
Certification; and that CMS create opportunity to submit data on measures should only review the measures
educational programs to help clinicians that are available and applicable to their available to a clinician or group given
and groups understand the multiple scope of practice. We are not requiring their chosen submission mechanism
submission option. A few commenters that MIPS individual clinicians and claims, registry, EHR or QCDRto
asabaliauskas on DSKBBXCHB2PROD with RULES

recommended making more quality groups submit via additional determine if they could have reported
measures available under each of the submission mechanisms; however, on additional measures. A few
submission mechanisms so MIPS through this proposal the option would commenters recommended that CMS
eligible clinicians have sufficient be available for those that have only offer multiple submission
measures within a single submission applicable measures and/or activities mechanisms as an option that could
mechanism. One commenter stated it available to them. As discussed in earn a clinician bonus points to
would inadvertently advantage large section II.C.7.a.(2)(e) of this final rule recognize investment in an additional
practices that may be better equipped to with comment period, beginning with submission mechanism. One commenter

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recommended that reporting using more burden and complexity around the use clinician to use multiple submission
than one submission mechanism be of multiple submission mechanisms. we mechanisms would penalize them for
required for a given performance period are not requiring that MIPS individual something out of their control,
only if the MIPS eligible clinician or clinicians and groups submit via specifically development of specialty-
group already has an additional additional submission mechanisms; specific eCQMs, noting that even with
submission mechanism in place that however, through this proposal the software certified to all 64 eCQMs,
could be utilized to submit additional option would be available for those that fewer than 6 have a positive
measures. have applicable measures and/or denominator. A few commenters
Response: We are not requiring that activities available to them. As expressed concern with how this
MIPS individual clinicians and groups discussed in section II.C.7.a.(2)(e) of this proposal would interact with the
submit via additional submission final rule with comment period, measure validation process to determine
mechanisms; however, through this beginning with the CY 2019 whether a clinician could have reported
proposal the option would be available performance period, we will apply our additional measures, specifically
for those that have applicable measures validation process to determine if other expressing concern that it would require
and/or activities available to them. As measures are available and applicable eligible clinicians to look across
discussed in section II.C.7.a.(2)(e) of this only with respect to the data submission multiple mechanisms to fulfill the 6-
final rule with comment period, mechanism(s) that a MIPS eligible measure requirement and that MIPS
beginning with the CY 2019 clinician utilizes for the quality
performance period, we will apply our eligible clinicians should not be held
performance category for a performance accountable to meet more measures or
validation process to determine if other period. With regard to a specialty
measures are available and applicable look across submission mechanisms,
measure set, specialists who report on a and potentially invest in multiple
only with respect to the data submission speciality measure set are only required
mechanism(s) that a MIPS eligible mechanisms, because CMS is making
to report on the measures within that additional submission mechanisms
clinician utilizes for the quality set, even if it is less than the required
performance category for a performance available.
6 measures. If the specialty set includes
period. With regard to a specialty measures that are available through Response: We are not requiring that
measure set, specialists who report on a multiple submission mechanisms, then MIPS individual clinicians and groups
speciality measure set are only required through this policy, beginning with the submit via additional submission
to report on the measures within that 2019 performance period, the option to mechanisms; however, through this
set, even if it is less than the required report additional measures would be proposal the option would be available
6 measures. If the specialty set includes available for those that have applicable for those that have applicable measures
measures that are available through measures and/or activities available to and/or activities available to them. As
multiple submission mechanisms, then them, which may potentially increase discussed in section II.C.7.a.(2)(e) of this
through this policy, beginning with the their score, but they are not required to final rule with comment period,
2019 performance period, the option to utilize multiple submission methods to beginning with the CY 2019
report additional measures would be meet the 6 measure requirement. In performance period, we will apply our
available for those that have applicable addition, for MIPS eligible clinicians validation process to determine if other
measures and/or activities available to reporting on a specialty measure set via measures are available and applicable
them, which may potentially increase claims or registry, we will apply our only with respect to the data submission
their score, but they are not required to mechanism(s) that a MIPS eligible
validation process to determine if other
utilize multiple submission methods to clinician utilizes for the quality
measures are available and applicable
meet the 6 measure requirement. In performance category for a performance
within the specialty measure set only
addition, for MIPS eligible clinicians period. With regard to a specialty
with respect to the data submission
reporting on a specialty measure set via measure set, specialists who report on a
mechanism(s) that a MIPS eligible
claims or registry, we will apply our
clinician utilizes for the quality speciality measure set are only required
validation process to determine if other
performance category for a performance to report on the measures within that
measures are available and applicable
period. set, even if it is less than the required
within the specialty measure set only
Comment: A few commenters 6 measures. If the specialty set includes
with respect to the data submission
expressed concern that this policy could measures that are available through
mechanism(s) that a MIPS eligible
clinician utilizes for the quality substantially increase costs and burden multiple submission mechanisms, then
performance category for a performance for MIPS eligible clinicians, as it may through this policy, beginning with the
period. require a MIPS eligible clinician or 2019 performance period, the option to
Comment: Many commenters did not group practice to purchase an additional report additional measures would be
support our proposal to allow data submission mechanism in order to available for those that have applicable
submission of measures via multiple report 6 measures, and another measures and/or activities available to
submission mechanisms or expressed commenter expressed concern for them, which may potentially increase
concerns with the proposal. Several financial impact on small and solo their score, but they are not required to
commenters expressed concern that it practices. A few commenters stated that utilize multiple submission methods to
would add burden, confusion, and it would increase costs to vendors, meet the 6 measure requirement. In
complexity for MIPS eligible clinicians which would be passed on to customers addition, for MIPS eligible clinicians
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and groups, as well as vendors, possibly and patients. One commenter expressed reporting on a specialty measure set via
requiring them to track measures across concern regarding decreased claims or registry, we will apply our
mechanisms based on varying productivity, and increased opportunity validation process to determine if other
benchmarks and to review measures and for coding errors. A few commenters measures are available and applicable
tools to determine if there are additional expressed concern that they may be within the specialty measure set only
applicable measures. required to report on measures that are with respect to the data submission
Response: We understand the potentially not clinically relevant. One mechanism(s) that a MIPS eligible
commenters concerns with regards to commenter noted that requiring the clinician utilizes for the quality

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performance category for a performance measure and associated submission EHR, these two submissions would be
period. mechanism. scored separately, and we would apply
Comment: One commenter Comment: One commenter requested the submission with the higher score
recommended that CMS withhold the clarification on how the data towards the quality performance score;
option for submission through multiple completeness will be determined if we would not aggregated the score of
mechanisms in the quality category for reporting the same quality measures via the registry and EHR submission of the
future implementation, or until CMS multiple submission mechanisms, for same measure. This approach decreases
has become comfortable with the data example, if a clinician utilized two the likelihood of cumulative
received in year 1 of the program. submission mechanisms to report the overcounting in the event that the
Response: We agree with the same measure, would 50 percent data submissions may have time or patient
commenter and due to operational completeness need to be achieved for overlaps that may not be readily
feasibility concerns, we have each submission mechanism or for the identifiable.
determined that this proposal will be combined data submitted. Another Final Action: After consideration of
implemented beginning with the CY commenter asked how CMS will take the public comments received, we are
2019 performance period. By the time into consideration data that is submitted finalizing our proposal at 414.1325(d)
this proposal is implemented for the CY using the same submission mechanism, with modification. Specifically, due to
2019 performance period, we will have but using two different products or operational reasons, and to allow for
greater familiarity with which the way services, specifically data submitted additional time to communicate how
data is submitted to CMS based off from two different certified EHRs in a this policy intersects with out measure
submissions from the CY 2017 single performance period when applicability policies, we are not
performance period. clinicians switch EHRs mid- finalizing this policy for the CY 2019
Comment: One commenter asked that performance year. performance period. For the CY 2018
Response: In the CY 2017 Quality performance period, we intend to
CMS confirm that a MIPS eligible
Payment Program final rule, we continue implementing the submission
clinician would be allowed to submit
finalized that for the quality mechanisms policies as finalized in the
data using multiple QCDRs under the
performance category, an individual CY 2017 Quality Payment Program final
same TIN/NPI or TIN because allowing MIPS eligible clinician or group that rule (81 FR 77094) that individual MIPS
submission via multiple QCDRs in submits data on quality measures via eligible clinicians and groups may elect
single TIN could serve as a pathway EHR, QCDR, qualified registry, claims, to submit information via multiple
forward for greater specialist or a CMS-approved survey vendor for submission mechanisms; however, they
participation within multispecialty the CAHPS for MIPS survey will be must use one submission mechanism
groups. assigned measure achievement points per performance category. We are,
Response: A MIPS individual eligible for 6 measures (1 outcome, or if an however, finalizing our proposal
clinician or group would be able to outcome measure is not available, beginning with the CY 2019
submit data using multiple QCDRs if another high priority measure and the performance period. Thus, for purposes
they are able to find measures supported next 5 highest scoring measures) as of the 2021 MIPS payment year and
by other QCDRs that would provide available and applicable, and we will future years, beginning with
meaningful measurement for the receive applicable measure bonus points performance periods occurring in 2019,
clinicians, and those measures are for all measures submitted that meet the individual MIPS eligible clinicians,
applicable. Consistent with the policy bonus criteria (81 FR 77282 through groups, and virtual groups may submit
finalized in the CY 2017 Quality 77301). Consistent with this policy, we data on measures and activities, as
Payment Program final rule (81 FR would like to clarify that for applicable, via multiple data submission
77282 through 77301), we would like to performance periods beginning in 2019, mechanisms for a single performance
clarify that beginning with the CY 2019 if a MIPS eligible clinician or group category (specifically, the quality,
performance period, if a MIPS eligible reports for the quality performance improvement activities, or advancing
clinician or group reports for the quality category by using multiple instances of care information performance category).
performance category by using multiple the same data submission mechanism Individual MIPS eligible clinicians and
instances of the same submission (for example, multiple EHRs) then all groups that have fewer than the required
mechanism (for example, multiple the submissions would be scored, and number of measures and activities
QCDRs), then all the submissions would the 6 quality measures with the highest applicable and available under one
be scored, and the 6 quality measures performance (that is, the greatest submission mechanism may submit data
with the highest performance (that is, number of measure achievement points) on additional measures and activities
the greatest number of measure would be utilized for the quality via one or more additional submission
achievement points) would be utilized performance category score. As noted mechanisms, as necessary, provided
for the quality performance category above, if an individual MIPS eligible that such measures and activities are
score. As noted above, if an individual clinician or group submits the same applicable and available to them.
MIPS eligible clinician or group submits measure through two different We are finalizing our proposal with
the same measure through two different mechanisms, each submission would be modification. Specifically, we are not
submission mechanisms, each calculated and scored separately. We do finalizing our proposal for the CY 2018
submission would be calculated and not have the ability to aggregate data on performance period, and our previously
scored separately. We do not have the the same measure across multiple finalized policies continue to apply for
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ability to aggregate data on the same submission mechanisms. We would the CY 2018 performance period. Thus,
measure across submission only count the submission that gives the for the CY 2018 performance period,
mechanisms. Similarly, data clinician the higher score, thereby virtual groups may elect to submit
completeness cannot be combined for avoiding the double count. For example, information via multiple submission
the same measure that is reported if a MIPS eligible clinician submits mechanisms; however, they must use
through multiple submission performance data for Quality Measure the same identifier for all practice
mechanisms, but data completeness 236, Controlling High Blood Pressure, categories, and they may only use one
would need to be achieved for each using a registry and also through an submission mechanism per performance

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category. We are, however, finalizing a methodology for assessing the total measures for several of the data
our proposal beginning with the CY performance of each MIPS eligible submission mechanisms, yet still
2019 performance period. Thus, clinician according to performance required that certain types of measures,
beginning with the CY 2019 standards and, using that methodology, particularly outcome measures, be
performance period, virtual groups will to provide for a final score for each reported.
be able to use multiple submission MIPS eligible clinician. Section To create alignment with other
mechanisms for each performance 1848(q)(2)(A)(i) of the Act requires us to payers and reduce burden on MIPS
category. use the quality performance category in eligible clinicians, we incorporated
determining each MIPS eligible measures that align with other national
(2) Submission Deadlines clinicians final score, and section payers.
In the CY 2017 Quality Payment 1848(q)(2)(B)(i) of the Act describes the To create a more comprehensive
Program final rule (81 FR 77097), we measures and activities that must be picture of a practices performance, we
finalized submission deadlines by specified under the quality performance also finalized the use of all-payer data
which all associated data for all category. where possible.
performance categories must be The statute does not specify the As beneficiary health is always our
submitted for the submission number of quality measures on which a top priority, we finalized criteria to
mechanisms described in this rule. MIPS eligible clinician must report, nor continue encouraging the reporting of
As specified at 414.1325(f)(1), the does it specify the amount or type of certain measures such as outcome,
data submission deadline for the information that a MIPS eligible appropriate use, patient safety,
qualified registry, QCDR, EHR, and clinician must report on each quality efficiency, care coordination, or patient
attestation submission mechanisms is measure. However, section experience measures. However, as
March 31 following the close of the 1848(q)(2)(C)(i) of the Act requires the discussed in the CY 2017 Quality
performance period. The submission Secretary, as feasible, to emphasize the Payment Program final rule (81 FR
period will begin prior to January 2 application of outcomes-based 77098), we removed the requirement for
following the close of the performance measures. measures to span across multiple
period, if technically feasible. For Sections 1848(q)(1)(E) of the Act domains of the NQS. While we do not
example, for performance periods requires the Secretary to encourage the require that MIPS eligible clinicians
occurring in 2018, the data submission use of QCDRs, and section select measures across multiple
period will occur prior to January 2, 1848(q)(5)(B)(ii)(I) of the Act requires domains, we encourage them to do so.
2019, if technically feasible, through the Secretary to encourage the use of (2) Contribution to Final Score
March 31, 2019. If it is not technically CEHRT and QCDRs for reporting
measures under the quality performance For MIPS payment year 2019, the
feasible to allow the submission period quality performance category will
to begin prior to January 2 following the category under the final score
methodology, but the statute does not account for 60 percent of the final score,
close of the performance period, the subject to the Secretarys authority to
submission period will occur from limit the Secreta